vodafone mhealth solutions insights guide evaluating mhealth adoption barriers human behaviour (1)

7/30/2019 Vodafone mHealth Solutions Insights Guide Evaluating mHealth Adoption Barriers Human Behaviour (1)

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Evaluating mHealthAdoption Barriers:Human Behaviour

Vodafone mHealth Solutions

Insights Guide

mhealth.vodafone.com


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Vodafone mHealth Solutions 3

Vodafone mHealth Solutions Insights Guide

WelcomeWelcome to our rst Health Debate publication theInsights Guide. Our aim is to provide some evidence-based stimulus that will encourage all those workingin the different areas of healthcare to consider the

innovation opportunities that are now available to them.We believe that real progress can only be initiated whenall stakeholders look beyond traditional horizons andshare ideas that challenge the status quo so that together

we can identify new ways of addressing current issues.

The opinions expressed in thisdocument are not ours but they arethose of independent experts whoseviews we respect even if we dontalways agree with them. I thankthem for the time and effort theyhave invested in exploring this topic.I believe they have important things

to say that should be of interest toanyone concerned with the long-termfuture of the healthcare industry.

We hope this document can offer yousome insights that will provide theimpetus to generate positive change.It is the rst of a series and we lookforward to hearing your response toour ideas in the months to come.

Axel Nemetz

Head of Vodafone mHealth Solutions

The Vodafone Health Debate series is part of our continuing commitmentto thought leadership in healthcare. It brings together senior pharma, publicand private health stakeholders to learn, share and debate on issues and newthinking brought forward by renowned thought leaders and industry experts.


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Table of contents3 Welcome

4 Table of contents

5 Scope and denitions

6 What patients and healthcare professionals say

8 An overview of mHealth opportunity

10 Evaluating behaviour to marketedmHealth services

14 Adopting technology: understanding thechallenges for healthcare professionals

16 Understanding health psychologyand the science of behaviour

26 Vodafone mHealth Solutions

26 References


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Scope and denitions

mHealth: application of mobile andnetwork technologies to improvehealthcare outcomes or efciencies;For the scope of this report, wefocus on patient and healthcareprofessional centred mHealth servicesincluding remote care and healthcare

professional mobilisation

mHealth services: includes any software,hardware, and services required to makethe end-to-end mHealth solution

Patients: includes both consumersi.e. healthy individuals, and peoplewith a long term or acute condition

HCPs: healthcare professionals includingnurses, primary and secondary caredoctors, specialists, and pharmacists.

The guide will focus on behaviours within the maturemarkets and maintain the following denitions throughoutthe report:


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What patients and

healthcare professionals say

Results show a genuine interest in usingmobile technology to improve patient careand increase efciencies. However veryreal concerns exist around its reliability, thecost of implementation and the ability ofpatients to use it. The following commentsare included in this report to give the readeran indication of the responses we receivedon specic topics.

Before analysing the changing attitudes towardsmHealth initiatives, Vodafone commissioned research1in order to better understand the current approach tohealthcare delivery amongst healthcare professionalsand their patients.

Stakeholder Group What they want from mHealth

Specialists To help manage data and make the best use of technology

GPs To empower their patients and help them manage chronicdiseases

Nurses To access instructional information or patient details on-the-go

Pharmacists To help them manage patient prescriptions, ensure accuracyand help with patient compliance

Patients To better manage and track their illnesses

Table 1 What HCPs and Patients say

What patients have to sayPatients can see the benet of mHealthbecause improved access to informationenables them to become more activelyinvolved in their own care. This isparticularly true for those with chronicconditions such as diabetes or high blood

pressure. Mobile technology can helpthem to monitor their condition outside

a hospital environment. It means morepeople can enjoy a normal life but canreact swiftly to receive treatment shouldthe need arise.


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What healthcare professionalshave to sayThe majority of healthcare professionals seethe advantages of mHealth but within thesector different emphasis is given to differentelements. For example, nurses and GPs aremost concerned with improving patientcompliance. GPs also see that mHealthtechnology can reduce unnecessary patientvisits and therefore cut costs. Nurses on the

other hand believe that mHealth initiativesmay well reduce administration time, whichwill in turn allow them to spend more timecaring for their patients. Finally specialistsand pharmacists believe that mHealthsolutions can improve communicationwith GPs so that they can share diagnosisand learnings more effectively.

Here is what they have to say:

Despite this enthusiasm mHealth adoption has not been scaled as muchas one would have expected. Subsequent editions of the Vodafone InsightsGuide will explore other reasons for this in more detail but here, in the rstof the series, we will focus on what some would argue is the main barrier totake up human behaviour.

Improving quality of life

After I rst had my rst heart attackfor the three weeks between the rstone and the second one I had to takemy blood pressure half a dozen timesa day at the doctors ofce, and I couldhave just used my phone to record it athome instead

Cardiac Patient, UK

Reassurance

In my hospital group, we get in touchover the Internet. Theres someone thereto answer your questions 24 hours a day,either a doctor or a nutritionist. I can do

it from home or work, and it gives mepeace of mind.

Diabetic Patient, Spain

Discretion

I dont want other people to feel sorryfor me because Im a diabetic, so I dontwant, if I take out a cell phone, everyoneto know oh, the poor guy is a diabetic.

Diabetic Patient, South Africa

Caring for patients

It would be nice to be sat with thepatient and have a phone to registerwhat youre doing, what youve done,and have that recorded and logged.

It shouldnt be a nursing job, should it? It takes about two hours a daywriting the notes.

Nurse, UK.

Improved communicationbetween professionals

mHealth will be an added value becausethe general practitioner will learn aboutdifferent pathologies by receivinginformation from the specialised doctor.

Specialist, Spain

The following quotations are examples of the main benets which were highlighted.


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An overview of

mHealth opportunity

The mHealth market is still very younghowever it is clear that the opportunity fortechnology driven healthcare is thrivingas a result of a changing healthcare

environment. Remote, intelligent

monitoring and diagnosis for example, hasthe potential to enhance quality of life,improve healthcare efciency and offsetburgeoning healthcare costs from a growing,ageing and increasingly obese population.

In a way, we are victims of our own successand by reducing the causes of death manymore people are now living into age bandsthe world hasnt experienced before wherethey need more care and more expensivecare. Healthcare services around the worldare therefore under pressure to increase thequality of care to patients at a time whenthe global population is aging, the burdenof chronic disease is rising and the economic

conditions are challenging. In Europe, forexample, the over-65s, whose healthcarecost burden is four times that of youngerages, will account for at least 25% ofthe population by 20402. Alongside this,unhealthy lifestyle choices such assmoking and poor diet, the increasing riskof and concern around the potential impactof pandemic diseases, the limited number

and uneven distribution of healthcareworkers, poor drug distribution and thelengthy development cycles of newmedicines are combining to make thecost of healthcare almost unsustainableparticularly in mature markets.

In addition, many healthcare providers indeveloped markets are encumbered bylegacy infrastructures that have been unableto adapt to meet the changing needs ofthe very people they were designed to

protect. Small wonder that managementconsultants McKinsey predict that if left as itis, healthcare costs could reach 30 per centof GDP by 2040. The OECD is not far behindwith costs reaching 30 per cent of themedian GDP by 2070. In emerging marketssuch as Africa where adult mortality rates areover 400 per 1,000 populations, alongsidecost, lack of infrastructure, limited access totreatments and poor quality medicinesare the core healthcare problems.

Looking ahead it is hoped that smartertechnologies will help to improvecommunications between patients,healthcare providers and those that pay andmanage the system. As a result this has thepotential to improve patient freedom andindependence, reduce the overall cost andimprove patient care. This view is supportedby McKinsey that estimates that the tele-health or mHealth industry will be worthover US $50 billion by the end of the decade.

A major global challenge is how to look

after our elderly and the chronically ill.Many believe that robotic assisted careand remote monitoring will offer viablesupport. Today growing numbers of publicand private organisations have moved onfrom basic systems of nurse visits and arealready providing tele-health based supportto monitor vital signs through data links,give advice over the phone and allowremote imaging. Text based support ofmultiple patients has also proved highlyeffective from both therapeutic and

economic perspectives in many countriesfrom the Philippines to South Africa,Germany to Brazil.

By Dr Tim Jones, Founder and Programme Director ofFuture Agenda, a global open foresight initiative


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In the next decade telemedicineconnectivity will provide 24/7 medicaldata sharing between patients andhealthcare professions with video links,

wearable monitoring equipment and in-home sensors tracking movement, bodytemperature and other vital signs. Theconsequence of this will be that patientswill be able to retain their independencefor longer and so better enjoy life outsidethe mainstream care system. Somecommentators as a result envisage a

slow-down in the recent growth of nursinghomes as a greater proportion of the elderlyremain at home. While some suggest that

this in turn could mean increased physicalisolation, the ambition for others is to usetechnology, particularly mobile technology,to prevent people from feeling lonely. In aworld where on average family support forthe older generation will continue to declineand the cost of providing personal carerswill continue to rise, elderly patients andthose with long term chronic diseases areincreasingly likely to see some step changesin support over the next few years.

In addition to automated care there is

general consensus that better use of

patient data is vital to improve efciencies particularly for those with on-going,chronic conditions such as diabetes. Tech-savvy diabetic sufferers already benetfrom a growing number of mobile phoneapplications that can help record and trackindividual measures, diet and performanceand there are increasing numbers of systemsthat allow the sharing of data betweenpatients and their doctors. Building on this,several organisations support the notionthat peer-to-peer and expert patient groups

may have as much inuence on individualbehaviour as the more traditional patient-healthcare professional relationship, soexpect to see more patient data becomingmore visible and more shareable acrossplatforms and systems in years to come.

If we can utilise the opportunity that theubiquity of mobile communication offers,we can better facilitate the delivery of moreefcient and effective healthcare. 70% of thesix billion3 mobile subscribers in the worldtoday live in developing countries wherethe need for the provision of care services atpoint of need is greatest.

Experience has shown us that there is agreat willingness to use mobile technologywhere the general provision of baselinehealthcare is weakest. Therefore it is perhaps

unsurprising to see that these parts ofthe world, unencumbered as they are bylegacy infrastructures, have demonstratedan ability to be nimble in their adoptionof new solutions that can deliver decentperformance at a low cost. Indeed theemerging world has become a case studyfor healthcare innovation.

A good example of how mature marketsare learning from others can be foundin India where Narayana Hospital hasused a combination of business modeland process innovation to lower the costof cardiac surgery and in doing so hasrevolutionised the access, volume and reachof its facilities to become one of the fastestgrowing healthcare businesses in the world.According to the WSJ, Jack Lewin, CEO of theAmerican College of Cardiology, the largenumber of patients passing through theNarayana facilities allows individual doctorsto focus on one or two specic types ofcardiac surgeries and so develop particularskills. Narayana has not only become the

best place to have heart surgery but it hasalso become the go-to facility for all aspiringcardiac surgeons globally.

Jack Lord, CEO of Navigenics, author of theinitial perspective on Health for the FutureAgenda Programme observed that, on theprovisioning of healthcare, inertia seemsto be the greatest force and went on topredict that the next decade is not to bea time of change but instead a time thatstressors on the system become

progressively evident; increased burdensof demography and chronic illness willremain unabated. IBM in their SmarterPlanet analysis builds on this by saying,

The problems with our healthcare systemare well known and well documented andendlessly debated. Whats not so apparentis that many of them arise because ourhealthcare system isnt, in fact, a system.The need to address the rationale for this

inertia is pressing and it seems clear thatmobile technology has a key role to playin facilitating change.

We are in a perfect storm. Youve got healthcare reform; youve got an economic

downturn... we have a shortage of providers. We have a pressure to adopt electronic

records. Weve got an aging population. And yet, at the same time we have these

emerging new information, communication technologies that can help us navigate

that perfect storm.

Dale Alverson, President of the American Telemedicine Association

Whether in the developing

economies or in the West mobiletechnology has a signicantrole to play. It can dramaticallyimprove the efciency ofhealthcare delivery models, fromsimple text message reminders,to improving complex supplychain processes in remote areas.It is also well suited to improving

patient care, offering medicalprofessionals the ability to collectreal-time diagnosis for clinicaltrials, giving chronic diseasesufferers the chance to live more

comfortably and independentlyat home and providing healthcareworkers access to information sothat they can treat more patientsmore effectively.


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Evaluating behaviour

to marketed mHealthservices

As mHealth initiatives evolve from pilot tomainstream, this section identies somecommon attributes of the more successfulinitiatives operating today across a numberof countries in the developed world.

A rapidly evolving space, favouringthe newcomermHealth combines the mobile, IT and

healthcare industries, which all have

different players, payers, cultures, clock

speeds and attitudes towards security,privacy and quality. This dynamic area

favours newcomers, and indeed most of

the companies referenced in this section

are venture-backed start-ups with rapidly

growing user bases and strong cash positions.

A space that covers both healthcareand wellnessThe clearest distinction betweendifferent companies is between healthcare and wellness; the former tend to beregulatory-approved medical devices andservices used by doctors, while the latter,such as calorie counters, tness buddiesand sleep monitors, are targetedat consumers. Wellness solutions

generally use behaviour change to

deliver wellness goals (such as loweringcalories, or improving a 5k run time)while healthcare solutions are often datagatherers as part of a larger clinicalprocess (such as heart monitors and mobileMRIs (Magnetic Resonance Imaging)).Tools for chronic disease management

such as diabetes, hypertension andasthma tend to draw from both camps,and represent some of the most excitingopportunities for lowering costs andimproving patient outcomes.

The attributes listed here are categorisedaccording to adoption, engagement andimpact (also see gure1). These wontapply equally to all companies, howevermany successful companies exhibit themajority of these attributes.

By Stephen Johnston, Founder and CEO of Fordcastle LLCwhich helps develop companies to build opportunityaround mobile technology, healthcare and longevity

Figure 1 The common attributes ofsuccessful mHealth services

IMPACTENGAGEMENT

ADOPTION

Simplicity

Empathetic design

Comprehensiveness

Interactive

Customer delight

User value

Joined-up solutions

Clincal and economic results


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Adoption

1. SimplicityGoogles Android and Apples iOS have

made great strides at making complex,multi-featured smartphones simple, andhave been rewarded with a combined 68%market share globally in Q3 20114. However,the majority of devices in peoples handsin developed countries are still dumb, andhealthcare patients in particular are likelyto be less tech savvy than average. Indeed,one recent study found that only 52% ofpatients with chronic diseases were Internetusers at all5 (let alone mobile Internet users),well below the average adult penetration

of 78%6

.

Text messaging services are effective atdelivering basic services, since they work onalmost every phone and the recipient reads95% of text messages within four minutesof receiving.

Voxiva, founded in 2001, providesText4Baby that delivers three texts a weekto prospective mothers after they registertheir birth date using a short code. The textmessages contain educational content,reminders and surveys. Now with 235ksubscribers, the service is growing at 15kusers per month, and signicantly, only33% of all users ever registered havecancelled the service.

This set it and forget it concept works well;passive services tend to retain users betterthan those constantly requiring data entry.Many calorie counter apps have ounderedfor this reason, whereas wellness devicessuch as the Withings Wi-Fi enabled bathroom

scale, the Fitbit wearable body monitor andthe Zeo sleep tracker all automate datacapture and entry after initial set up.

2. Empathetic design

Marek Pawlowski, founder of the MobileUser Experience Conference, used the termempathetic design to describe the processof ensuring designers really do take theneeds of the end user into consideration.

At one of their workshop sessions onhealthcare, participants in a brainstormingon mobile health devices for the elderlywere given gloves and shaded glasses toillustrate the challenges faced when peoplewith visual and physical impairments had to

interact with mobiles.

The Jitterbug phone and service made byGreat Call is a mobile solution designedwith the needs of aging users in mind withlarge keys and simple service options. Theyoffer a medication reminder service for an

additional monthly charge that deliversregular voice reminders to subscribers totake their medication.

3. ComprehensivenessFor some mHealth solutions, the key tosuccess lies in their comprehensiveness.

Founded in 1998, Epocrates is one of thefew public companies listed here and haveover a decades experience collecting andorganising content for physicians. Their drugreference, educational and clinical solutionsare in use by 1.3m healthcare professionals,including over half of the doctors in the US,who rely on its comprehensiveness.

On the consumer side, the iTriage app that

has been downloaded almost three milliontimes, sees up to one million monthly usersand boasts 10,000 (mostly positive) reviewson Apples Appstore. CEO Peter Hudson,MD, highlights its industry-leading contentaggregation capabilities (in addition tostrong customer support) as a key successfactor. They provide information aboutsymptoms as well as integration intohundreds of partner healthcare providers,resulting in what is effectively becoming aWhite Pages of consumer health services.

Engagement

4. InteractiveProviding personalised feedback that allowsusers to see the results of their actions

makes for a more engaging experience.

The Consumer Health Information

Corporation (CHIC) found that a quarter ofall smartphone apps (not just health apps)were dropped after the rst go, and three-quarters were no longer used after the tenthtry. Reasons for dropping an app includednding a better one (34.4%), its lack ofuser friendliness (32.6%), or it not beingengaging enough (15.8%). Of a survey of

395 consumers, about 80% said theywould be more motivated to use an appthat would analyse data they recordedand provide feedback7.

Healthcare technology companyWellDoc, Inc. understands this.Their agship DiabetesManager, the rstmobile diabetes management solution toreceive FDA 510K clearance, providessimple and proven, clinical and behaviouralevidence-based guidance about how tomanage glucose levels, medications,activity, diet and several other parameterswhich affect total diabetes wellness.Company President Anand Iyer sees it asa mobile virtual coaching solution thatprovides basic clinical and behaviouralsupport, effectively providing an interactivecoach in peoples pockets.


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Weve seen many programmes that have been grant funded. The grant ends and theprogramme ends. So we ask people to think about sustainability and to come up with

a business plan that makes sense. Whats the data we need to collect to show the

impact and what are the indicators of success. Youve got to be able to determine that.

Telehealth will not be sustained or adopted unless we can show that it improves health

outcomes and reduces costs.

Clinician, US

5. Customer delight, even funFunction has generally triumphed overform in the healthcare business, while inthe consumer electronics and mobile space

a vast amount of time is spent thinkingabout user experience.

The Boston, MA-based start-upFitnessKeeper has attracted 6m users to itsRunKeeper service without spending a centon advertising. Founder & CEO Jason Jacobsthinks that building a product peoplelove is the key to this organic growth. Inaddition, he cites the social component,accelerated by Facebook and Twitter, andthe community support, as success factors.

Delight doesnt have to be reserved forwellness apps. The founders of VC-backedstart-up Massive Health are user experienceexperts without healthcare backgrounds,and have vowed to bring customer delightto the eld of healthcare. They are currentlybeta testing their rst product, a diabetesmanagement solution, and CEO SuthaKamal says that ultimately hes lookingfor the grin on the users face. In addition,innovative projects are using MicrosoftsKinects motion-sensing solution to assess

early disease symptoms8, and gamedynamics are being used to encouragemental and physical tness, such as withHumanas Colorfall.

Impact

6. User valueSmart solutions do more than just

replicate existing processes on smallscreens, they look for ways in which theprocess can be done better, deliveringlasting user benets that signicantlyoutweigh any costs incurred.

Azumios Instant Heart Rate app deliversjust what it promises, taking the heart ratefrom the nger in just a few seconds. Ituses the phones in-built camera combinedwith the light from the ash to track colourchanges in the skin that show heart rate.

This innovative approach, together with anattractive user interface has resulted in thisapp being downloaded 10 million times byOctober 2010; at $0.99 a download, this hasbecome one of mHealths success stories.Solutions that make full use of the multi-faceted power of the mobile can delivereven more value to users than those that

just replicate existing ofine processes.This is especially important when oneconsiders the myriad of existing distractionson the phone that are already competingfor the users attention, such as keeping upwith social networks, consuming media orplaying games.

7. Clinical and economic resultsHealth-focused solutions that can showboth clinical and economic benets to allparties will see the most rapid uptake.

AirStrip Technologies delivers near real-timewaveform and other relevant clinical data toa physicians smartphone. The companysOB product has been so successfulin reducing human errors, that somemalpractice insurance companies in theUS are subsidising the costs for doctorsto use it. In addition, internal studies haveshown that their cardiology solution cancut short the time from EMS (EmergencyMedical Services) to surgery by up to 15minutes, and reduces the average timespent in hospital following a heart attackby almost a day.

A scientic study reported in the September2011 edition of the journal of the AmericanDiabetes Association, shows that WellDocsDiabetesManager delivered a 1.9% declineover a year in the key diabetes metric(A1C Glycated haemoglobin), comparedto 0.7% in the test group. With each 1%increase in the A1C level representing a

~40% increased risk of micro and macro

vascular complications for diabetes patients,and an average monthly cost of over $300,results such as these make it more likelythat physician and regulators will rapidlyadopt and embrace these services.


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8. Joined-up solutionsSuccessful services tend to be integratedinto other aspects of the patients lifeand the healthcare system. This explains

the need for solutions as opposed totechnologies, according to Joe Smith fromWest Wireless Health Institute.

Microsoft Health Vaults Sean Nolan says,The world doesnt need one more isolatedsilo of data for tracking whatever. mHealthservices have to exist within the contextof the formal and informal care team.The Health Vault platform connects 300applications and 70 home care devices,and collaborates with a growing numberof healthcare providers.

FitnessKeeper offers joined-up solutionscoming from the wellness perspective.They recently launched a Health Graph APIthat supports an ecosystem of third partydevelopers that integrate with the platformand share afliate revenues. Partnersinclude many of the more promisingmHealth devices, such as sleep trackerZeo, the Withings wireless scale and socialgaming site Fitocracy.

Health Graph API has been given a boostsince Google pulled the plug on its healthservice. The failure of this initiative was dueto many reasons, but one was undoubtedlythe lack of integration and incentives toencourage participation with other playersin the health system, i.e. physicians andpayers. As a result, there was only limitedbenet to the users for going to the effortof uploading data into a siloed service.

Towards an understanding of user adoption barriers

The attributes listed in this section can inuence a number ofdecisions that go into the creation of a new mHealth solution, fromdesign of the rst user experience, to the business partnerships thatneed to be in place for the solution to be lastingly effective. However,in the same way, these attributes can also help to better understand

the barriers that currently prevent widespread user adoption factorssuch as complexity, poorly thought out designs, and disjointedsolutions that dont integrate into a patients life.

Signicant opportunities beckon for savvy entrepreneurs who cansuccessfully navigate between the two worlds, incorporate many ofthese attributes and in so doing, start to deliver on mHealths potentialof lowering costs and improving patient care.


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Regulatory complexity, nancialconstraints, entrenched infrastructuresand poor investment in technologycombined with a lack of understandingby technology providers has meant thatdigital innovation in healthcare has beenslow to take hold. However, given changinghealthcare needs of an increasingly ageingpopulation and the challenges presentedby the current economic crisis, thereis renewed interest in the potential ofmHealth and Internet solutions to helpreduce costs, increase efcienciesand effectiveness.

This section considers the practical reasonsbehind the slower than expected adoptionof digital health technologies and discusses

experiences from other sectors that couldpotentially help create wide scale adoption.

Creating a better customer-centricexperienceUnderstandably patients and physicianswould prefer to manage healthcareservices in a simple and straightforwardway. However many life science companiesto date have not acknowledged this andhave instead set up a disparate set ofinterfaces which are tiresome.

Across life science companies, thedefault approach to online interaction isa standard static website9 where productinformation can be found in one place,company information in another, andthere is no obvious overview of the value-added services provided. This is a hugemissed opportunity.

Perhaps life science organisations shouldlook to other sectors for guidance.Amazons website for example can give

you almost anything you need with asingle search function and a few clicks.Every purchase follows the exact samesimple pattern and you dont need toll out your payment or delivery data asecond time. In addition, Amazon usessocial recommendations and predictivemarketing to help you as an individualto nd the things you didnt even know

you needed yet. One trustworthy partnerthat knows your preferences and supports

you accordingly, a dream come true...so why are life sciences companies notembracing this?

Admittedly, the industry is learning butslowly. Take for example the US baseddigital healthcare portal HealthGrades.It helps patients nd doctors accordingto their need. Lets say you need to nda cardiologist close to New York, then

you can nd more than 2500 possible NYcardiologists on this portal. How do youknow which physician will provide thebest care? Through high-volume patientratings, the physicians are rankedconveniently and you can immediately

nd the physician of your choice.

Delivering clear user benetThe last twenty years were aboutbecoming digital, the next twenty yearswill be about becoming clever with digital,says Chairman of Across Technology, PeterHinssen. This might sound trite but in orderto use technology customers must rst

By Fonny Schenck,CEO at Across Health, an

international management

consultancy for digitalinnovation in life sciences

Adopting technology:

understanding the challengesfor healthcare professionals


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understand its benets. Indeed in a waytechnologists have been distracted by theconcept of technology and instead ofworking towards better services have spenttoo much time trying to build a cleverersystem. AirStrip CEO Alan Portela explainedthis in the context of Electronic MedicalRecords, EMRs: EMRs are platforms, Thesame way that your computer has an[operating system] EMRs are the OS.You benet from the apps that you put ontop of the OS, while you dont benet somuch from the OS10. Of course withoutthe Operating System the apps would notwork but still, the point needs to be made.mHealth technology providers would dowell to bear this in mind when consideringproduct innovations.

Right place, right technology, rightdoctor and right patientIn the future healthcare will be deliveredthrough a multitude of channels and it

is clear that mobile devices will have adistinct role to play in this. But mobiledevices are not the only option, otherdevices or channels should and will beused when more appropriate.

Not only do certain devices t certain

contexts better, the services providedon these devices should integrate asseamlessly as possible with the normalwork patterns of the healthcare professionaland patient. Failure to achieve this has inthe past led to signicant nancialinvestment without any material gain.

mHealth technologists need to consider

how best to t their service into thepatients daily lives or the physiciansnormal workow. The key question theyshould ask is how can we make their liveseasier, and not more difcult?

Understanding pricing andreimbursement dynamicsThe internet has radically transformedpricing models and many organisationsare battling to adapt to this. Increasinglyfreemium models combined withadvertising have great success. There

are all sorts of ways of adopting afreemium approach. For example, in hisbook Free: the Future of a Radical PriceChris Anderson describes how practice

management software is given away bythe Californian company Practice Fusion.The physicians are given the free version ofthe software with ads or can buy an ad-freeversion for 100 USD per month. Additionalvalue is created by selling anonimisedpatient charts to medical associationsfor research purposes. 100,000 medicalprofessionals are currently using theservice and the number is growing, with350 new users every day11.

Standard healthcare practice issomewhat different to this. In developedeconomies common practice is to rely onreimbursement from the government, inwhich case the technology is considered(nearly) free for the end user. In mostcountries, doctors are paid based on thenumber of patients they treat or meetin the consulting room. If doctors are

rewarded in this way it is very clear whythey are reticent in adopting technologiesthat reduce face-to-face interactions. Fromthat perspective, indeed: What to them isthe benet of remote monitoring?

An interesting recent initiative from

Australia underscores the importanceof reimbursement/incentives in the

adoption of new technologies: sinceJuly 2011 and for the next four years,the Australian government is activelypromoting telehealth by providing bonusesto healthcare professionals that adopttelehealth technology and that participatein video-consults with patients.

Crossing the (mHealth) chasmGeoffrey A. Moores book Crossing the Chasm describes the greatest

difculty that many disruptive technological innovations face in crossing

the chasm between innovators and early adopters. It is clear that the

priorities of doctors and healthcare workers are very different from that

of the technologist. The best stimulus to the adoption of mHealth is to

turn the above hurdles into drivers: putting the customer at the heart of

your business, offering unsurpassed user benets, designing for the right

use context, and offering an attractive pricing model.


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Understanding health

psychology and thescience of behaviour

IntroductionHaving evaluated a number of mHealthservices on the basis of success in useradoption, this last section of the reportaims to contextualise the current stateof mHealth through relevant academic

literature on user adoption behaviour.

There is a growing corpus of literaturedocumenting the development of differentmHealth technologies. Alongside technical

aspects, discussions explore issues of

dissemination and implementation, andthere have been a number of preliminaryevaluations in terms of impact on healthoutcomes, patient satisfaction andbehaviour change. What is largely absentfrom the published literature, however,is rigorous research on the process ofuptake and adoption of mHealth fromthe perspective of both the patient andhealthcare provider. In this section,therefore, we address two main questions:

What existing theories and research can

be used to explain adoption behaviour oftechnologies of health?

What constitute the main barriers tomHealth adoption?

Existing theoriesHealth-related behaviour is highly complexand efforts to understand and account

for individual and collective behaviourand its determinants continue across

multiple disciplines. Drawing on theoreticalframeworks from anthropology, health

psychology, sociology and cultural

epidemiology, the following presents a briefoutline of selected theories of behaviouras they relate to healthcare practices andhealth system response.

The Health Belief ModelFirst developed in the 1950s by socialpsychologists Hochbaum, Rosenstock andKegels12,13, this model attempts to explainand predict health behaviours by focusingon the attitudes and beliefs of individuals.The model is structured around four key

concepts which account for an individualsreadiness to act:

perceived susceptibility perceived severity perceived benets perceived barriers

Additional concepts, cues to actionand self-efcacy, were later added tohelp the Health Belief Model addresshabitually unhealthy behaviours such assmoking, overeating and being sedentary

(conditions that mHealth technologieshave addressed). Belief and healthmotivation are seen to be conditionedby socio-demographic variables andthe psychological characteristics ofthe individual. The model has beenused extensively in determining healthpromotion activities14. However, it fails toincorporate features such as the inuenceof previous experience, advantages of mal-adaptive behaviour, behavioural intentionand perceived control.

By Dr Juliet Bedford, Founder and Director of Anthrologica,a research based consultancy rm specialising in theapplied anthropology of healthcare


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Theory of Planned BehaviourAn extension of the Theory of ReasonedAction, formulated by Ajzen and Fishbeinin 198015, which sought to estimate

the discrepancy between attitudeand behaviour, the Theory of PlannedBehaviour (also see gure 2)16 predictsdeliberate behavioural intention usingthree constructs: behavioural beliefs,normative beliefs and control beliefs.

Behavioural beliefs (attitudes towardsthe behaviour) are determined by thenotion that a specic behaviour will havea concrete consequence.

Normative beliefs (the subjective norm)are concerned with views about how

people the individuals social network will regard the behaviour in question,plus personal motivation to full theexpectation of others.

Control beliefs (perceived behaviouralcontrol) refer to an individualsperception of their ability to perform agiven behaviour, belief about access tothe resources needed in order to

act successfully.

These predictors lead to intention, the

precursor of behaviour. In general, themore favourable the attitude and thesubjective norm, the greater the perceivedcontrol, the stronger a persons intentionto perform the behaviour in question. Theadvantage of the practical application ofthis theory is that it takes into accountmotivational aspects of personal controland the inuence of social networks, butit can be limited by an over-emphasis ofpsychological factors whilst under-valuingstructural forces such as the reduced

availability of resources or poor access.

Healthcare Utilisation ModelDeveloped by Anderson and Newman17in the 1970s, this socio-behaviouralmodel groups three clusters of factorsthat can inuence health behaviour in alogic sequence:

predisposing enabling need factors

This model was developed to investigatethe use of biomedical health services,although later versions were extendedto include other healthcare sectors18.

It centres specically on treatmentselection and includes both materialand logistical factors that are not fullyaccounted for in other models. Kroeger19elaborated the model to include healthservice system factors, referring to thestructure of the healthcare system and itslink to the socio-political macro-economyin which it operates. The advantage ofsocio-behavioural models is the varietyof factors, organised into categories,that make interventions for therapeuticaction (or lack of it) feasible. It permits theestablishment of correlations with goodpredictability, but not specication ofhow and why the different factors affect

therapeutic selection.

Behavioural

attitude

Subjective

norms

Perceivedbehavioural

control

Intention Behaviour

Figure 2 Theory of Planned Behaviour


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Social Cognitive TheoryFrom the 1960s onwards, Bandura20 hasdeveloped social cognitive theory toexplain how people acquire and maintain

certain behavioural patterns. Based onthe earlier Theory of Social Learning21

three dominant factors were seen tobe constantly inuencing each other:environment (social and physical),people and behaviour.

Bandura suggested that individuals are

capable of learning not just from their ownexperiences, but vicariously, from thosearound them. Known as ObservationalLearning, the process is regulated by foursub functions:

attentional processes retention processes production processes motivational processes

Linked to this is self-efcacy (behaviouralcapability), the beliefs in ones capabilitiesto organise and execute the coursesof action required to produce givenattainments22. Social Cognitive Theory

is used extensively in the design ofhealth education and health behaviourprogrammes and as the basis forintervention strategies.

Other theoretical considerationsKleinmans concept of ExplanatoryModels23 contain explanations of aetiology,onset of symptoms, pathophysiology,course of sickness and treatment, toelaborate specic systems of knowledgeand values centred in the different social

sectors and sub-sectors of the healthcaresystem24. In political-economies ofhealth, factors categorising availability,accessibility, affordability and acceptabilitystill dominate.

Many models assume that individualsengage in a rational process of weighingthe benets and costs of behaviouralchoices and select the course of action

with the most favourable cost-benetratio (as in the Health Belief Model, theTheory of Planned Behaviour, and theSocial Cognitive Theory), but affectiveassociations25 have also been shown tobe inuential. Unlike these continuum

theories (which place an individual alonga continuum of action likelihood), stagedtheories, such as the TranstheoreticalModel of Behaviour Change (also see

gure 3)26 have arisen from doubt thatlinear models are fully capable of capturingthe complex processes that underliedecisions to engage in health behaviours27.

Ideally, as Hausmann-Muela concludes,a contextualised analysis of healthbehaviours should (a) be necessarilyinterdisciplinary, combining naturalsciences with social sciences approaches;(b) not fail to consider that the studiedcontexts are part of a historical process;(c) combine micro with macro levels; and(d) triangulate qualitative and quantitativeinvestigation techniques28.

To understand behaviour associated withthe adoption of technologies of health,we need to overlay theories derived fromsocial and behavioural science, withtheories of user engagement drawn fromthe elds of Information Communicationand Technology.

Stage 4: ACTION

Dedicates considerable

time and energy; make

overt and viable changes;developes strategies to

deal with barriers

Stage 3:PREPARATION

Intends to take action

and makes small changes;

needs to set goals

and priorities

Stage 2:CONTEMPLATION

Aware the problem exists

and serious evaluation

of options but not

committed to

take action

Stage 1:

No intention to

change, often unaware

of the problem

Stage 6:EVALUATION

Assessment and feedback

to continue dynamic

change process

Stage 5:ADAPTATION /MAINTENANCE

Works to adapt and adjust

to facilitate maintenance

of change

PRE-CONTEMPLATION

Figure 3 Transtheoretical Model of Behaviour Change


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Diffusion of Innovations TheoryRogers Diffusion of InnovationsTheory (also see gure 4)29 is the mostinuential in understanding how aninnovation inltrates a population (or not),

and provides a comprehensive structurefor understanding individual adoption and,collectively, diffusion. It focuses on theconditions that increase or decrease the

likelihood of a new idea, product orpractice being adopted.

Rogers presented four stages:the innovation itself; diffusion (orcommunication) through the social system;time; and consequences. He argued thatan innovation is an idea, practice, or objectthat is perceived to be new by an individual

or other unit of adoption, diffusion isthe process by which an innovation iscommunicated through certain channels

over a period of time among the membersof a social system, and communication isthe process in which participants createand share information with one anotherto reach a mutual understanding.

The theory suggests that becauseinformation ows through networks,opinion leaders in that network play arole in determining the likelihood thatthe innovation will be adopted, but

additional intermediaries (change agentsand gatekeepers) are also inuential.Five categories of adopter are outlinedwhich follow an S-shaped diffusion curve:innovators, early adopters, early majority,late majority, and laggards.

Diffusion research has focused on vemain elements: the characteristics ofan innovation which may inuence itsadoption; the decision-making processthat occurs when individuals considerthe adoption; the characteristics of

individuals that make them likely to adoptan innovation; the consequences forindividuals and society of adopting theinnovation; and communication channelsused in the adoption process. Closelylinked to Diffusion of Innovations Theoryis Network Analysis and Social NetworkTheory30 and Critical Mass Theory31.

0

100

75

50

25

Marketshare%

Innovators2.5%

EarlyAdopters13.5%

EarlyMajority34%

LateMajority34%

Laggards16%

Figure 4 Diffusion of Innovations Theory

Market penetrationLevel of adoption


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Technology Acceptance ModelThe Technology Acceptance Model isone of the most inuential extensionsof Ajzens Theory of Reasoned Action and

Theory of Planned Behaviour. Developed byDavis32, 33 it is an information systems theorythat models how users come to accept anduse a technology. It replaces Ajzens attitudemeasures with two technology acceptancemeasures: perceived usefulness (the degreeto which a person believes that using aparticular system would enhance his or herjob performance), and perceived ease-of-use (the degree to which a person believesthat using a particular system would befree from effort). The model assumes thatwhen someone forms an intention to act,they will be free to act without limitation,whereas in the real world, there will bevarious constraints. Other models explainingacceptance perceptions and behavioursassociated with Information Technologyinclude Computer Self-Efcacy34, Task-Technology Fit35 and the MotivationalModel36.

United Theory of Acceptance and Useof Technology / Unied Theory ofConsumer Acceptance Technology

Recent studies have sought to integratesome of the prior models. Venkatesh37examined eight of the most commontheoretical frameworks and models usedto explain individual adoption and use oftechnology and brought together theirmost salient characteristics to form a uniedtheory, United Theory of Acceptance andUse of Technology (also see gure 5).

This presents four key determinants of use(performance expectancy, effort expectancy,

social inuence and facilitating conditions)and four moderators of individual use(gender, age, experience and voluntariness).

Similarly, Kulviwat38 designed the ConsumerAcceptance of Technology framework bymerging two previously unrelated models,the Technology Acceptance Model and

the Pleasure, Arousal and Dominanceparadigm of affect (developed as a model inenvironmental-psychology by Mehrabain39,it suggests that all emotional responses tophysical and social environments can becaptured with three dimensions of affect:pleasure, arousal and dominance).

Sun and Zhang40 present a systematicanalysis of the explanatory and situationallimitations of existing technologyacceptance studies. They call for moreresearch into the individual and contextualfactors that are often neglected in

technology acceptance studies but canbe critical in the application of thetheoretical models, and identify tenmoderating factors considered to beinuential (voluntariness, the nature of tasksand professions, technological complexity,the purpose of using technology, individualvs. group technologies, gender, individualintellectual capabilities, experience, ageand cultural background).

Adoption behaviours barriers andways to overcome themAs the eld of mHealth matures, ourunderstanding of adoption behaviours

(both positive and negative) associatedwith health technology uptake will developin scope and nuance. To date, research inthis area has been limited. Extrapolatedfrom the existing literature, the followingbarriers to uptake should be seen as astarting point for future work. AlthoughmHealth is often positioned or perceivedas being a disruptive technology byboth healthcare providers and receivers,interaction often varies between stakeholdergroups. We therefore present the dominantbarriers faced by healthcare providers(both as individuals and organisations),and those faced by patients, despite someinevitable overlap. Ways to overcomethese barriers are then set out.Several quotes are included which areadapted from the stakeholder researchcommission by Vodafone1.

Figure 5 United Theory of Acceptance and Use of Technology

Performance

expectancy

Effort

expectancy

Social

influence

Facilitating

conditions

Behavioural

intention

BehaviourAge

Experience

Gender

Volun

tarinessofuse

Voluntariness


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Table 2 Barriers to health technology adoption healthcare providers 41, 42, 43, 44, 45, 46, 47

Barrier DenitionClinical issues Doubts arising over the quality of care provided (associated with risks of litigation, particularly in the USA)

Cost / reimbursement How to recoup investment and pass on user cost (especially a concern in the USA)

Lack of evidence Scant evidence about the effectiveness of technology or how mHealth improves clinical outcomes,workow etc

Lack ofuser-engagement

Inadequate physician support base and physician-based leadership, limited involvement in design orimplementation, concern about technology

Organisationalstructure

Concerns about integration and interoperability of mHealth in current structures

Privacy Issues of condentiality and consent

Security Regarding transmission, storage and retrieval of clinical data

Work load andtime management

Increased time spent and reluctance about outside of ofce hours responsibilities

Workow modalities Lack of processes and procedures around collection, organisation, analysis of data, and how to implementaction needed

Clinical issues:

The moment youve got continuousmonitoring on, there might be a legalimplication there. What happens if thenetwork goes down or you go to a part ofthe hospital where its not available andsomething wasnt picked up purely forthat reason? Now whos liable? Is it thedata? Is it the company that makes thedevice? Is it the hospital or the companythat built the hospital? Is it the doctorat the end?

Thought Leader, UK

Cost / reimbursement:

Well, Id say cost, understanding of itsutility, anytime you bring in somethingnew particularly in the eld oftechnology convincing people that itsbringing betterment, an advantage tothe way that theyre doing things, thatsalways a barrier.

Pharmaceutical, US

There is a concept called cost-

opportunity which means that themoney that is spent on sanitary issues istaken from another placeif you spendon telemedicine and not in ambulancesor emergency systemsits a greatresponsibility the way you spend money.

Hospital, Spain

Lack of evidence:

Theres quite a few pilot studies ,butthe problem with all of those is theyrevery small studies. Or even if they goon a year, theyre a very select groupof patients. You havent done it onpopulation scales so trying to nd acost justication for that

Thought leader, UK


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Organisational structure:

One of the real challenges for us is howwe can improve our systems so that theywork more efciently. Its all very wellimproving your back end systems, but

youve got to be able to access them.The key problem for us is how do youmake these nice, shiny, new systemsavailable to the clinicians? And our keygoal is to make patient information, realtime patient information, regardless ofwhich system it comes from, availablefor the clinician at the point of care.

Hospital Manager, UK

Privacy:

We increase in a signicant way therisk of not respecting peoples right toprivacy as well as privacy of datathereis no proper regulation to protect dataand the patient in the face of the spreadof information through telemedicine.

NGO, Spain

Lack of user-engagement:

The only thing that these professionalssee is that they will be overburdened.Its clear that if they now have 100patients, with telemedicine they couldhave many more.

Academic, Spain

Work load and time management:

If you sent out 100 reminders, nowyouve got to respond to those 100replies. Even with email, you can sendemails to patients who are on theirmobiles, but its difcult because then

you start getting the email queriescoming in, and you cant sit and respondto things electronically all the time.Medically, legally youre going to runinto trouble. So, its getting aroundthose constraints.

GP, SOUTH AFRICA

If a lot of people were using it, it wouldrequire an extra employee to managethe information.

GP, SOUTH AFRICA

Workow modalities:

What needs to be done is to gatherefforts to create a common information

system; in such a way that every Spanishcitizen could easily and rapidly locate all

their clinical history in a database and bydoing so be capable to share with someother doctors, no matter where you wereat, Switzerland or Madrid.

GP, Spain


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Table 3 Barriers to health technology adoption patients48, 49, 50, 51, 52

Barrier DenitionCost How to fund direct and associated costs

Design of thetechnology

Complex interface, obtrusive technology, physical ability to use (condition or impairment specic)

Disruption to dailyroutine and normalhealthcare practices

Perceived or actual disruption. Common fear among patients that utilising technology risks reducing orloosing direct contact with their doctor.

Lack of evidence About usefulness, ease-or-use, and accessibility

Lack of knowledge No or limited knowledge about mHealth prohibits initial patient interaction

Lack of access As consumers, patients have little independent access to mHealth unless it is directly recommended orprescribed (although availability and access to both clinical and non-clinical smartphones apps is increasing)

Level of technologyliteracy

Digital divide and variable levels of skill (level of threat perceived by new technology)

Privacy Who has access to their data (security is not such a concern for patients who regarded it as technical issuethat should be solved prior to technology roll out)

Reliability of thetechnology

Risk of technical failure or error leading to elevated health risk

Cost:

500 pounds will mean something tome, but for someone else 500 poundsmight be perceived as a lot of moneyand its very hard with these costings.And whatever way you look at it if youretalking about equipment at a heavy priceits got be means tested because theNational Health Servicejust cant afford it.

Diabetic Patient, UK

Disruption to normal healthcarepractices:

I think doctors will have longer intervalsbetween visits because youre morecovered, which would make me doubt,because I like face-to-face contact withmy doctor, being able to tell him aboutmy problems.

Diabetic Patient, Spain

Level of technology literacy:

Any device must be user-friendly. Youshouldnt need a degree to use it. Its nefor a 20 year old, but we didnt grow upwith technology the way young peopledid. I dont know how to set up my DVD.

Diabetic Patient, ZA

Privacy:

One of the biggest hurdles that

youre going to have to go over is theability to ensure patients that their datais protected, that it is not being usedfor example, by insurance companiesto prevent them from getting insurancebecause they have a particulargenetic marker.

Thought Leader, US


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Table 4 Ways to overcome barriers53, 54, 55, 56, 57, 58, 59, 60, 61, 62

How to overcomethe barrier Denition

Complement/augmentnormal practices

Ensure technology adds value and supplements healthcare practices

Cost / reimbursement Make it cost effective, develop new business models

Data specications Collect targeted data that is required

Design and properties Maximise the user experience through targeted interface that allows for personalisation, customisation andadaption, make it desirable

Evidence Rigorous evaluation and evidence-based results

Increase awareness,

knowledge base andrecognition

Build consensus around what is available, when, why and what the advantages are (users can not adopt

technologies unless they know they are available). Reducing the gap between the pre- and post-useperceptions of patients and healthcare providers is important and could lead to higher acceptance rates

Increase accessibility Increasing the visibility of mHealth is only part of the equation. Available technologies must be packagedand offered in ways that enable consumers to access them directly.

Organisationalsupport

Underpin technology with systems and processes to support organisational structures in which it willoperate; ensure integration, interoperability and standardisation

Overall, ensure thebenets outweighthe costs

Adoption will follow an S-shape diffusion curve that necessitates sustained engagement and commitmentfrom the end users

Privacy Solve legal and regulatory issues about privacy and control of data

Security Solve technical issues around security of transmission, storage and retrieval of clinical dataTraining Train individuals in the application and practicalities of the technology

User development Engage all stakeholders in product development to ensure its key requirements are met, it is user driventhrough participation, and is scalable

Workow modalities Ensure information collection, analysis, and dissemination is efcient

Applying behavioural theories intechnology and healthIn the adoption and utilisation of mHealth,

behavioural attitudes are likely to be moreimportant to progress than technology [34].As Martins [32] concludes, mHealth per seis not enough to improve healthcare, sinceimproving care, or supporting it, is more thanjust giving professionals (and patients) easieraccess to information and communication.

It is widely acknowledged that mHealthhas the potential to improve healthoutcomes, but we must demonstratehow and understand why. The barriers

identied as prohibiting the ready adoption

of mHealth can be divided into ve inter-related categories: social; clinical; technical;economic; and organisational or logistical

(also see gure 6).

Mechanisms and strategies can be putin place to minimise their impact: employingeffective design theory will result inincreasingly rened and appropriateinterfaces being developed; employingorganisational change theory will createstable institutional systems and workowsthat can incorporate technology to improveefciency; employing targeted socialmarketing will raise awareness of

the technologies existence.

The potential of mHealth is extensiveand supports a fundamental change in theway that HCPs and patients interface with

healthcare. Whilst changes are required forHCPs to be able to cope with new healthcaredemands and sustain the quality of care, as adisruptive innovator, the fact is that mHealthintroduces change, and change maynegatively impact its adoption and causenon-uptake. In the quote on the next page,for instance, concerns about eliminatingcolleagues jobs prohibit the ready adoptionof technological interventions.


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To date, research into moderators ofindividual use (such as gender, age andfamiliarity with technology) has beenscarce and their inuence on uptake isnot well understood. Age, for example,has been postulated as an importantdeterminant, suggesting that elderly people

will be less able or willing to use mHealthtechnologies. It appears obvious that theyounger tech-literate generation, for whomcommunication technologies are inherent

in daily life and social interaction, wouldbe the predominant audience for mHealth.In fact, preliminary ndings show that ifolder people are adequately trained, if thetechnology is appropriate and if it enhancestheir quality of life, age is not necessarily abarrier to its adoption63

However good the technology andstructures to support its use become,mHealth will be redundant unless end-users, both patients and HCPs, are willing toutilise the technology in a sustained way.This is why it is crucial that we understandthe behavioural attitudes associated withmHealth adoption.

ConclusionmHealth is a rapidly expanding eld withexciting scope for innovation and growingdemand for technological solutions to

health issues. As in other industrialisedcountries, the majority of Americansnow refer rst to the internet for healthinformation, before visiting a healthcarepractitioner64. Frequently, patients reportthat their interaction with such informationchanged the way they thought abouttheir health problems and prompted themto change their behaviour65. The mobilephone, as the fastest adopted technologyin history has, with its expandedfunctionality, provided mHealth with a

pervasive and fertile platform66, 67

It cuts down on medical labour costs, and Im not interested in that, becauseI dont want my colleagues or I to be out of a jobits a very good idea, but Ithink theres an ulterior motive behind it and its not the wellbeing of people.

GP, Spain

SOCIAL CLINICAL

TECHNICALECONOMICAL

LOGISTICAL / ORGANISATIONAL

Figure 6 mHealth adoption barrier categories

The eld of mHealth poses new questions and challenges forhealthcare and it is not yet fully understood what impact it will haveon health-related behaviour from the patient, provider or industryperspective. Theories will develop concomitantly across multipledisciplines to enable us to better understand adoption behaviourconcerning mHealth68, 69. In turn, we must incorporate that knowledgeinto the development of health technologies to ensure appropriate,relevant and sustained engagement. As Norris [43] concludes, thedevelopment and exploitation of mHealth demands a top-downstrategy or framework to match and encourage bottom-up innovation.

Capitalising on the advancement of mobility in the communicationsage, health and healthcare are now part of societys interconnectedness.There remains much to learn, but by incorporating strategies forprevention, detection, monitoring, treatment and support, mHealth has

a critical role to play in delivering real-time, real-life healthcare in thetwenty-rst century.


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Vodafone mHealth

SolutionsThis Insights Guide has been commissioned byVodafone mHealth Solutions.

The mHealth Solutions team is a business unit within Vodafone that looks afterthe Global Healthcare industry. Our mission is to improve healthcare outcomesand quality of life by giving patients and healthcare professionals increasedexibility and freedom, for example, by more effective remote monitoring ofpatients, the provision and exchange of health related information or improved

stock management for pharmaceutical drugs.Vodafone mHealth Solutions leverages todays omnipresent mobile connectivityto implement quickly deployable solutions which are appreciated by multiplestakeholders. Our services are used by patients, health authorities, pharmaceuticaland medical device companies and health insurance providers.

For more information, please visit mhealth.vodafone.com or join our liveHealth Debate on LinkedIn at mhealth.vodafone.com/linkedin

ReferencesExperts interviewed between 6-20 September 2011

mHealth companies: AirStrip Technologies (Bruce Brandes,

EVP and Chief Strategy Ofcer) ChangeTech (Erik Rosen, CEO) iTriage (Peter Hudson, MD, CEO) Massive Health (Sutha Kamal, CEO) Microsoft Health Vault (Sean Nolan,

Chief Architect, Health Solutions Group) FitnessKeeper Inc. (Jason Jacobs,

Founder & CEO) Sensei (Robert Schwarzberg, MD,

Founder and CEO) Welldoc (Anand Iyer, PhD, President

and COO) WelTel (Richard Lester, MD,

Executive Director)

Voxiva (Jason Sims, CEO)

Industry thought leaders: Steve Dean, Founder, G51 Studio Marek Pawlowski, Founder, MEX - Mobile

User Experience Conference & Awards Joe Smith, MD, PhD Chief Medical Ofcer,

Chief Science Ofcer, West WirelessHealth Institute.

Gary Wolf, Founder, Quantied Self


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What patients and healthcareprofessionals say

1 Market research experts PSB (Penn Schoen Berland)held interviews and a series of small discussiongroups between March and April in 2011 in the UK,Spain and South Africa. In total PSB spoke to a 160health experts, health professionals and patients.

An overview of mHealth opportunity

2 UN Department of Economic and Social AffairsPopulation Division (2011). [online]. Accessed athttp://www.un.org/esa/population/

3 Wireless Intelligence Total Number of Connections.(2011). [online]. Accessed athttps://www.wirelessintelligence.com/Logged/Datatables.aspx?Show=1&KpiId=3&CvalId=0&RegionId=3826&CurrId=0&Begin=07/01/2009&End=07/01/2011&Spot=Spot

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5 Dolan, B (2011). Apps useful, familiar to tiny numberof patients. [online]. Accessed athttp://mobihealthnews.com/7090/apps-useful-familiar-to-tiny-number-of-patients/

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9 Across Health digital survey EMEA 2011. (2011).[online]. Accessed at http://www.slideshare.net/mdevuyst/across-health-digital-survey-7867399

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