Although it feels a little early in the year to be contrarian, I think that the industry is running before it can walk.  Do we really think doctors are ready to be start practising the mantra of “first I’ll dispense an iPhone app; if that doesn’t work I’ll give them an Android one; and if they’re still not better I’ll put them on the Symbian app - if that doesn’t cure them, nothing will.  They won’t come back after that!”.

I’m not knocking innovation in health apps.  As I’ve said before the industry probably needs to think more out of the box than it currently is, but there are already lots around and there will be more to come.  Whether they will transform our health is another matter, as is whether anyone will make money out of them.  A lot of the current thinking seems to be making unsupportable jumps and simply inflating the mHealth bubble.  Let’s look at whether it makes sense…

The headline figure that got everyone excited was a report from Kalorama estimating that the medical mobile apps market had grown from $41 million in 2009 to £84 million in 2010.  The inference is that 2011 will be the start of the hockey stick, with untold riches in the years to come.  Pyramid Research certainly think so, claiming that the number of apps will triple by 2012.  Even JWT rate mHealth as being in the top 100 things to watch in 2011, coming in at position 49!

There is no doubt that the growth of Apps stores have seen a surge in health applications, even though the definition of “health” often stretches seamlessly into lifestyle, sports and fitness.  Distimo have recently released a report covering the apps that have been released in 2010 which indicates that health and wellness is attracting plenty of interest.  It’s the second fastest growing area for applications for the iPhone, and the fifth fastest for both Blackberry and Android.  Symbian users are either much healthier or spending their time doing something else.  Those figures are not just a reflection of by the hopes of developers.  Pyramid research has been looking at the key players in the mobile healthcare chain and report that 70% of users would like to have a mobile application on their phone.  Bear in mind that only 20% of phones currently being bought are classed as smartphones, and there’s either a mismatch here, or the bulk of those being surveyed either don’t understand the question, or are a highly selected portion of the population.  That skew isn’t unusual - I’m constantly having to explain to devoted iPhone fans that it’s predominantly their friends who own them, not the other 95% of the population.

Incidentally, according to Neilsen the country with the highest percentage of smartphones, at least for younger users, is Italy.  Which makes one wonder whether smartphone ownership is somehow linked to the health benefits of the Mediterranean diet?  Or is it just about fashion?  I suspect the latter.  Incidentally, users in colder climates should be careful about trusting their health to a phone app, as Apple recently refused to repair a broken iPhone that had been used outside in Norway, claiming that using it below freezing invalidates the warranty.  I hope that doesn’t mean that mHealth can only be used in California, as that could upset all of the analysts’ predictions.  Companies in San Diego please note - there is another world.

Back to reality, and the question is who will make money out of mobile health apps?  Going back to the Distimo report, they believe that the high download volumes of free applications compared to paid ones will mean developers look for other ways to get money from the user, rather than the direct purchase price of the application.  That’s a trend that was very clear when I was speaking at Droidcon a few months ago.  Developers were bemoaning the fact that the days of making money from selling apps had gone.  Today they’re increasingly relying on advertising revenues, in-app purchases, or just being paid to write apps for larger companies.  Even that last option is getting less profitable as more apps developers come online and development tools make it easier to write them.

The Distimo report has an interesting set of rankings comparing free and paid apps across the main platforms.  It’s noticeable that there are no health apps in their top ten free listings, and only two paid health apps in any of the top ten lists - Sleep Cycle Alarm Clock for iPhone and Calorie Tracker for Blackberry.  (Possibly implying that iPhone users sleep poorly because of nightmares about Steve shuffling off his mortal coil, and that Blackberry users eat too much.) 

The various reports on the size of the market don’t spend too much time considering who will be writing health applications and why.  One of the early sectors, perhaps not surprisingly, has been the pharmaceutical companies, particularly in the US where they can promote their products to the public.  As they are using apps to hook users onto drugs (doubtlessly in a responsible way), these are invariably free.  Even paid for health apps are generally cheap.  According to vFluence the average is under $2 (Kalorama think it’s closer to $15, but that includes textbooks and medical references).  The $2 figure sets a price point which the market will find difficult to increase.  So business models need to be built around the provision of free apps. 

TO make the free app model one, one route this is to brand them.  Big Pharma’s already doing that, although they’ve recently started pulling some of their initial apps out of the Apple stores, which suggest the model still needs some tuning.  Of course there may be ways to get people to pay.  There has to be a market for celebrity health apps.  So next time Britney catches a cold or Heston has a haemorrhoid problem, expect to see a premium priced celebrity heath app on a phone near you, either getting you to pay to see them recover, or buying a new generation of celebrity endorsed medication to treat your celebrity look-alike bug.

Of course, once GPs have finished reorganising the NHS over here in the UK, I’m sure they’ll all be brushing up their Java skills and showering us with a range of celebrity doctor apps.  They already have a role model, as our former Health Minister - Lord Darzi, has written one.  So we’re secure in the knowledge that the NHS has been saved and are all smugly expecting to live to a hundred with no health problems other than the occasional bout of swine flu.  But we’ve still got lots of Tamiflu in stock, so that’s OK.

One area which does appear to have the potential to make some money is that of professional applications for doctors.  It’s the only area where the medical industry has been able to expand its pricing into the mobile world.  Many of these provide obvious benefit to doctors, but it’s unlikely that this pricing model will be sustainable outside the clinical world.

The number of different phone platforms doesn’t help the growth of this market.  Research4Gudiance’s survey expects health applications to gravitate to the iPhone and Android platforms over the next four years.  However, the iPhone may face a challenge over the next two years for applications that connect to patient sensors and consumer medical equipment.  That’s down to a self-inflicted problem.  Most of the health device manufacturers have decided to use Bluetooth for their wireless link.  Although both Apple and Android support Bluetooth, Apple has blocked the profiles that are needed for these health devices and require manufacturers who want to connect to an iPhone to incorporate a proprietary Apple encryption chip within their blood pressure meter, weighing scale, or whatever device they may be manufacturing.  That adds around $10 to the retail price.  Not surprisingly, most manufacturers resent this and are not supporting iPhone connectivity.  That gives Android, Blackberry and Symbian a distinct advantage as apps move from today’s position where users type in data, to the next generation, where that happens automatically.  Which means that Apple needs to decide whether to stay proprietary and lose out in the emerging connected consumer medical device arena, or embrace a more open approach.    

Going back to the analysts, what has been interesting is the different views on where users will purchase these health applications.  Research4Guidance in Berlin have been surveying customers about this.  Although they use apps stores today, the participants expect this to change.  By 2015, 65% expected to get apps from their doctors, 68% from clinicians and 56% from specific health related web sites.   Their survey is clearly about “traditional” health, as the main therapeutic areas that came up were the classic long term chronic conditions - diabetes, obesity, hypertension, asthma and COPD, with a strong showing for chronic heart disease as well.  As such, the move to a medical distribution chain may reflect regulatory issues, as well as a continuing trust in the medical profession, even if that means them deploying new tools.

Of course, the big question is how doctors will make the transition from dispensing pills to dispensing apps?  The survey highlights the dichotomy facing the GP - first of choosing apps for their own work, to help them to manage better, and then choosing apps to “sell” to their patients as part of their treatment.  Some analysts, like Pyramid see a role for the network providers here, but I’m not sure I do.  I was much more impressed by a company I met when I was chairing the Mobile Healthcare Industry Review at the King’s Fund before Christmas.   It was a new company called Devices 4 Ltd.  It’s structured as a non-profit organisation and has been working with the healthcare industry and is very aware of both parts of this problem.  James Sherwin-Smith, their Chief Executive, was presenting the results of a survey that they had undertaken to see how UK health professionals were using mobile technology.  80% of the respondents carry a mobile phone at work, almost half to allow them to access information on the internet or intranet.  Yet only 18% run a medical or health application.   That would double if the phone was provided to them with work related apps.  Over half of respondents, who were all health professionals, believed that they “would be more productive if they had a mobile phone for use at work”.  The survey also highlighted that within the UK, using a mobile phone in a medical environment is still not allowed or frowned on for over a third of those surveyed.

The survey informs the role that d4 is aiming to fill.  It’s quite shocking that over a third of health managers still see no benefit to medical staff using mobile phones.  Even where they are allowed or tolerated, there’s no coordination about which phone or network to use, or which applications might be relevant to which job.  Instead individual health workers are left to make that decision themselves.  d4 is aiming to be the glue that brings that together, allowing information and best practice to be shared and to act as a group purchasing organisation for UK healthcare professionals.  If you’re involved in healthcare, have a look at what they’re doing.

They’re not alone in understanding the problem.  In the US, the Greater New York Hospital Association (GNYHA) has put together their own mobile health applications marketplace, called happtique.  It has many of the same principles as d4, and I’m please to see they’re working together.  Amid the hype surrounding mobile apps, they’re both bringing a much needed injection of sanity to those who may soon be at the sharp end of deploying them.

And if you’re one of the 19% of doctors without a smartphone, keep on dispensing the pink pills, followed by the white ones, with the blue ones as the prescription of last resort…

Many reasons are put forward for that, ranging from the natural inertia of the medical industry, the barriers imposed by regulators, through to the difficulty in persuading doctors to hand over disease management to their patients.

Technology has been blamed in the past, but that’s no longer a valid reason.  Over recent years there have been major advances in sensors, wireless connectivity and processing power.  We certainly don’t have solutions to every problem, but there is a wide range of conditions where mHealth could provide significant benefits.  So what’s holding it back?

Next week the Mobile Health Industry Review at the King’s Fund in London will be bringing experts and VCs together to talk about business models.  I’ll be suggesting that mHealth isn’t the first industry to have suffered from this phenomenon.  Even for disruptive technologies, it often needs an unexpected and sometimes even unconnected industry to invent and develop a new application in order to drive things to a point where the disruption can be taken up and embraced by others.  One of the classic cases is the Internet.  Much of the development of streaming, payment mechanisms and user interface was driven by the porn industry.  Once that work was done, it was adopted by others, giving us the e-commerce, video streaming and compelling content that we now expect from every site. 

So, if Mobile Health is going to get anywhere it probably needs to follow the same course and forget about conventional medical thinking, (which generally involves a doctor), and embrace some more disruptive models.  To put it more bluntly, we need to find out what the equivalent of pornography is for healthcare.

You only need to look back ten years on the Internet to see how far the technology has moved.  Payment mechanisms a decade ago were relatively primitive.  It was a world before Paypal, when today’s giants like Amazon and Google were still Internet toddlers.  Streaming video and the ability to cope with large files were still in their infancy, with RealVideo only a few years old.  No-one would have believed the situation we have today, with high quality video on demand services for mobile phones and TV.

What is important to understand if you’re developing a Mobile Health business model is that the companies who are now at the forefront of delivering Internet services were not generally those leading the development of these features.   Most of today’s success stories hadn’t got a business model or a customer base that was making money at that point.  The industry which had that was pornography.  It developed a product that people would pay for, which had little if any regulation and which needed to innovate.  It succeeded and provided the foundation for many more conventional internet business models. 

I’d argue that in the western world mobile Health faces a similar dilemma.  We know we can do it, but most of the companies involved are trying to copy or extend their existing business models onto the internet or mobile networks.  They’re not being truly disruptive.  That’s largely because the management teams within these companies come from a traditional medical background.  It’s similar to what we saw in the first decade of the mobile phone.  The new operators were staffed with people who had grown up in conventional landline phone businesses and were fixated on the existing model of paying for calls on a per minute basis.  It took a long time for them to understand the disruptive nature of SMS and move towards bundled tariffs, rather than duplicating their fixed line experience.

That’s the problem.  How do we solve it?  The sports and fitness market is nibbling away at one edge, but that’s a relatively small market.  The bulk of the population doesn’t really engage in sport, and of those that do, an even smaller percentage are interested in instrumenting themselves up and becoming web connected.  That’s not to say it’s not a profitable market, but it’s small.  If we want to find opportunities with scale, we need to look into the High Street and the high circulation magazines to see what sort of “health” products people really spend their money on.

It’s not medicine as we know it.  It’s alternative health, vitamin pills, dieting aids and cosmetics - the palliatives for envy, hope, despair and guilt.  Fronted by men in white coats, or attractively upholstered young models, they sell the promise of a better you.  Consumers lap them up, and when they fail to deliver, turn uncomplainingly to the next purveyor of high tech snake oil.  That churn, and the need to grab the next customer, provides a fertile breeding ground for innovation.

These are markets which are looked down on by the medical community. That might be valid in terms of any evidence base for their efficacy, but their business models can teach the mobile health industry a thing or two.

Rather than selling an extension of today’s medical practice, they’re selling hope.  In many ways it’s an attractive business model as it has no regulation beyond the most basic definition of trade description, little expectation of working from the customer perspective, which means it can only over-perform, and relies on marketing techniques that are still relatively unknown in the medical industry (although not as much as you might hope or expect - see Carl Elliott’s “White Coat, Black Hat“).  The companies involved innovate regularly, without the stultifying board presence of consultants and academics who are trying to commercialise their personal great idea.  Which means they often succeed.

That percentage of success is interesting.  I’ve not found any hard evidence (and if anyone has it, I’d really appreciate it) about the success rates for medical start-ups, as opposed to alternative medicine start-ups.  The anecdotal numbers I’ve heard are that 80% of medical start-ups fail in their first five years, whereas it’s less than 25% for alternative medicine, albeit that covers a gamut of businesses.  If those number are correct, they deserve serious attention.

All of which implies that there is plenty of opportunity to learn from them.  It also suggests that the technology companies that are trying to persuade the medical start-ups to embrace their technologies might do much better to look further afield.  Some of the possibilities aren’t so different, but are far more likely to be purchased and used by consumers.

So think laterally.  Why don’t we market connected pill dispensers for vitamins and herbal cures?  What type of sensor do we need to convince someone that crystal healing is effective?   How can monitoring quantum flux keep your dog healthy?  Is it time to replace mHealth with mHomeopathy?  However loony the application, it should be possible to measure something and feed it back, and if it’s done well the consumer will keep on paying.  Once that’s cracked, the applications with real medical benefits can take advantage and try to piggy-back on that innovation.

Whatever you think of the porn industry, it gave us the internet that we have today.  Whatever you think about alternative medicine, its greatest legacy could be in helping to develop appropriate models for consumer healthcare.  If you’re interested, have a look at my presentation on alternative business models for mobile health and let me know what you think?

That change was heralded by a consultation on “Liberating the NHS”, which was slipped out before the summer holidays, probably in the hope that few would notice or respond to it before the deadline at the end of September.  It signalled a major change in direction, where control would be moved from the current Primary Care Trusts (PCTs) to consortia of General Practitioners (GPs).

That raises some concerns.  The first is that we don’t train GPs to be managers.  We still train them in much the same way we did a hundred years ago.  So the most likely effect is that all of the managers who get made redundant from PCTs will simply go and work for GP consortia.  And as there are far more of these, it just results in an even bigger set of people micromanaging.

The more worrying concern is what effect this will have on prescribing practice.  The consultation document keeps on trotting out the phrase “clinical evidence”, implying that the NHS and local GP practices base everything they do on good clinical evidence.  It’s a nice theory, and it would be nice to think that those developing this policy change believed in and supported it.  It should be possible - we have a body called NICE (The National Institute for Clinical Excellence) whose job is to promote it.  But as soon as everyone got back from their summer holidays, Andrew Lansley - the new Minister for Health, got out his rusty shears and castrated NICE.  It’s difficult to understand why, but the implications for the NHS and GPs are disastrous.  It’s goodbye to clinical evidence, and hello to whoever can get the most publicity for their favoured drug of the month.

NICE was one of the best ideas in the UK health system.  As well as collecting and disseminating evidence on best practice, it also took on the difficult task of working out the cost effectiveness of a drug or treatment.  In an ideal world, with unlimited money, we’d always give every patient the very best drug there is for their condition.  The problem is that this world is not ideal and money is limited.  With new drugs, particularly the ones that the tabloid press like to brand as “miracle drugs”, a course of treatment that adds twelve months to a patient’s life may cost £100,000, whereas one that adds nine months to their life is only £50.  Which means that someone has to make the hard decision as to which is “value for money”.

NICE did this using a formula to calculate a “Quality Adjusted Years of Life”.  If a drug was deemed to be cost effective, the NHS was allowed to prescribe it, otherwise it was not.  It wasn’t a perfect system, but it did a massively important job, as it allowed the NHS to decide where best to spend its money.  However, in an era, where patients look at healthcare provision as an absolute entitlement, it did not go down well with people who were denied drugs that they thought might squeeze out a few extra months of life.

The result was of this common sense approach was predictable.  When an expensive drug was rejected, a patient somewhere would find a consultant or GP who though it would be beneficial (and there always seemed to be one ready to get their fifteen minutes of fame), and who would support their campaign to be prescribed it.  It was manna to the tabloid press, who would run it as a story of human interest versus Big Brother.  Few UK politicians actually understand the basis of clinical evidence or risk analysis, as most, like Andrew, read politics or law rather than science and have a very sketchy concept of these principles.  Instead, their immediate reaction to any adverse publicity is to cave in to media pressure, throw NICE’s decisions out of the window and go for the photo-opportunity with the patient.

I’m not sure anyone expected Andrew Lansley to take the knife to NICE.  Nor is it obvious why he did it.  Polly Toynbee, writing in the Guardian suggested it may be tabloid pressure and support for big Pharma, whilst Private Eye’s excellent Phil Hammond thought it may be spite at NICE’s less than positive reaction to Lansley’s blatantly populist Cancer Fund.  Whatever it is, it’s difficult to retain any confidence in a minister who is disassembling a body that is respected as a model for clinical evidence around the world.

It’s also difficult to understand where he thinks this will end.  I responded to the consultation, warning of the problem that GPs would face if they were to take charge of making these decisions.  GPs aren’t trained to manage, and they certainly aren’t trained to resist the might of the national media.  Every patient that can persuade a publicist to take up their case now has the power to expose their GP to the nation as an unfeeling bastard - a medical scrooge who will be portrayed as being more interested in maximising their income than giving their patients access to the drugs they allegedly need.

Carl Elliott, in his book “White Coat, Black Hat“, gives some vivid examples of how pharmaceutical companies recruit and use doctors as Key Opinion Leaders to promote their most profitable drugs.  Whilst I suspect most of Pharma would prefer the return of NICE, as that’s a regime they know and understand, they’ll be getting out the cheque books and seeing who they can usefully add to their payroll.  Ironically, the Sunday Times newspaper recently published its guide to Britain’s Top Doctors.  It’s the next step forward on their peculiar love of league tables to categorise what the chattering classes should be aspiring to.  I wonder how many of the entrants in future years will gain their place based on their willingness to prescribe whatever their patient wants, inaugurating a new generation of celebrity GP?

By removing the ultimate authority, Mr Lansley has opened up a Pandora’s Box that has the potential to bankrupt the NHS by putting prescribing practice into the hands of tabloid editors.  If you’re planning to become ill, make sure it’s at the start of the financial year.  For with an evidence-free policy like this, where media exposure will determine the NHS’ drugs bill, anyone falling ill later in the year may find themselves limited to little more than bedside manner and aspirin.

As far as the medical industry is concerned, it’s business as usual, and hopefully more so, as more of us get older and less healthy.  But there are some interesting trends.  One of which is the increased prevalence of wireless connectivity.  In previous years equipment manufacturers were happy for nurses to jot down the readings from their instruments.  A few devices had wireless links, but they were the exception.  This year, particularly at the consumer end of the market, wireless was becoming the norm, at least at the top end of product ranges.

Almost all of that was Bluetooth.  I stopped counting after the first hundred devices, and that was in just two of the twenty halls.  ANT was in evidence, helped with a demonstration of a prototype X10 Nano phone from Sony Ericsson, which was using the ANT protocol to connect to a weighing scale, heart rate belt and pedometer.  Wi-Fi was there in a few products, but mostly confined to tags for asset management, and I failed to find a single ZigBee medical device.  There also seemed to be very little profile for the Continua Alliance in terms of products or signage.  Even The Intel stand was conspicuously Continua-free.

So what can you do with Bluetooth?  There’s always been a fair number of medical products with Bluetooth connectivity, but on the evidence of Medica it appears to have swelled from a trickle to a flood.  Although Bluetooth has developed a Health Device Profile, which allows devices to transfer data according to the IEEE 11073 standard Device Specialisations, most manufacturers have ignored this and are simply using Bluetooth as a cable replacement, developing their own proprietary protocols.  The disadvantage of this approach is that there is no interoperability between these products.  It means developers need to tweak their applications for each individual product.  In the longer term I hope that these products will move to interoperable designs, using either Bluetooth’s Health Device Profile, or the interoperable services that are being developed within the new Bluetooth low energy standard.

Nevertheless, the industry is obviously taking to heart the ability to record readings automatically.  There was stand after stand with glucose meters, each boasting ten or more different models, and in almost every case with at least one of them having a Bluetooth option.  To give an idea of the scale of Medica, I’d estimate that there were in excess of 2,000 different glucose meters on display, with a least a tenth of them incorporating a Bluetooth link.  There were a similar number of blood pressure meters, from cheap wrist based products, through to complex clinical devices, again with Bluetooth available in most ranges.

At the consumer end of the market, i.e. non-regulated devices, there were Bluetooth weighing scales from the leaders, as well as from the minnows on the shoe box cubicles in the China and Korea pavilions.  The medical companies seem to have got the message that Bluetooth is the radio for medical devices. 

In fact there weren’t many vital signs that you couldn’t measure using Bluetooth.  Companies were displaying ECGs, gait sensors, spirometers, pedometers, nasal and aural airflow monitors, CPAP pressure meters, thermometers, heart rate meters and even urine flow meters.

Of course, adding Bluetooth to a medical device doesn’t do any more than replace a cable.  What makes it a lot more interesting is when you connect it up to a health hub or mobile phone, collect the data and feed it into an application that provides useful input to a clinician or carer, or compelling feedback to the patient themselves.  A number of companies have developed down these routes and were displaying real commercial systems using Bluetooth enabled medical products.  The most prominent of these were Vitaphone, Bodytel and smartLAB.  Adding up the numbers they gave me, they claim to be monitoring around three quarters of a million users, mostly within Europe.  That’s a very respectable number for an industry that is still in its infancy and which is only just starting to develop its business models, particularly as that growth has been with proprietary products

It was surprising that these services are still very much in the minority.  I’d estimate that they account for less than a fraction of one percent of the companies at Medica.  That may be partly due to the fact that Medica is still very much an equipment show.  Most of the visitors still go there to buy hardware for their current medical business model, not to look at the potential disruption of a new, patient centric one.  But the equipment that will cause that disruption to accelerate is definitely beginning to appear on the stands. 

The other thing missing from Medica was medical and health apps for smartphones.  The previous week, research2guidance had predicted that by 2015, 500 million people will be using healthcare applications on their phones. A visitor to Medica would have barely realised that they exist, let alone that they exist in their thousands.   A few were around, but you needed to hunt them down.  That was a notable omission.  Coupled to the rise of connected products, they will enable a level of disruption that the current industry is still desperately trying to deny.  I was struck by the number of products designers who came up and asked me about Bluetooth low energy, as they see this as the technology that will drive this disruption.  It will take time for a critical mass of these products to appear, but when they do, Medica and the industry as a whole will face a greater change than any they have seen in the last fifty years.

Much of mHealth is invisible.  It’s not the high tech monitoring that we find in glossy medical device brochures, but far simpler, everyday applications.   Many of these use SMS, but mHealth extends through voice and video, and we’re already seeing local use of applications on iPhones and Android.  However, there is little coordination of deployment, and almost all that is happening is as a result of local initiatives. 

Let’s look at some of the examples.  Where better to start than midwifery - at the start of life itself?  Portsmouth NHS Trust has produced an excellent example of the benefits from giving staff access to patient’s medical records whilst they’re on the move.  The system uses a digital pen which the midwives use to write up case notes in a preformatted notebook when they visit the pregnant mothers-to-be.  The data from the pen is sent to their Blackberry using a Bluetooth link, and is then transmitted back to the hospital. The information is automatically entered into the patient’s notebook, providing a record of the pregnancy.

The system can alert the hospital staff to any problems in real time.  The application was developed by the trust, with input from physicians to help develop the notebook.  What brought it to life was when the project leader saw a digital pen being used and realised that it could transform the application.  He demonstrated the possibility to hospital staff and it was the midwives who stood up to express interest in trialling it.  Like most of the successful implementations of mobile health projects, they were closely involved in designing how it worked.  The result is that it follows established practices, but makes them much more efficient.  It’s claimed to be a “wild success” amongst the 130 midwives who are using it.  It cost the trust around £150,000 to develop and they believe it has already saved them over £220,000.

The Portsmouth example is an interesting one as most people would consider digital pens to be quite high tech.  One of the reasons that it’s done so well is that the technology “just works” - it’s not changing the way that the midwives work - it’s just letting them do the job more efficiently.  That’s an important message for anyone rolling out an application - those using it need to be able to see that it helps them.  And the best way to achieve that is to involve them in its design.  If users see the benefits, they’ll be enthusiastic about taking it up.

The same applies for applications that are directed at patients.  That’s why there has been spectacular success with SMS.  At the most basic level, SMS is being widely used for appointment reminders.  All sorts of claims have been made for how much this is saving the NHS, and I took a rather light-heated look at this is a previous blog.  Not as much is being written about what it’s doing to improve patient’s lives.  People miss appointments for all sorts of reasons.  Some because they start feeling better and don’t remember to cancel, others because they forget, some because they’re worried about what the diagnosis might be, and some because the condition has worsened and prevented them attending.  Reminders work for all of these, whether it’s just by clearing the appointment for another patient, or helping to ensure that they attend.  The latter is important, as delayed diagnosis can make it more difficult and expensive to provide a cure, adding cost to the subsequent treatment.  SMS reminders can help by catch a disease earlier and using ensuring patients don’t delay or prevaricate in being seen.

Where SMS really comes into its own is where it plays to the privacy and personal nature of a mobile phone.  Companies like iPlato have been instrumental in using this to assist a large range of trials sending personal medical notifications.  Last month Tower Hamlets started sending SMS invites to women in the borough to attend cervical screening sessions at their local GP surgery.  Estimates of the number of deaths in the UK from cervical cancer that could be prevented range from 900 to over 4,000 each year.  Providing personal messages is an effective way to get women into their GP surgery to reduce that number.

A similar strategy is being used by Sandwell Primary Care Trust to remind parents of under fives to take them to attend immunisation clinics.  The MMS saga has left the UK with an unfortunate legacy of low immunisation rates and services like this can help to redress that.

The point to emphasise about SMS is that people respond to messages that arrive on their phone.  They’re seen as personal, so they’re more likely to act upon them.  Having a text on a phone is much more immediate for most people than a letter that drops onto the doormat.  A good example of that was a campaign carried out by the Heart of Birmingham Primary Care Trust earlier this year.  They recruited 24 GP surgeries to send out messages promoting health checks to a target audience of 40 to 74 year olds for whom they had mobile numbers.  That’s not the demographic that’s normally associated with testing, but over 1,850 patients responded, representing a staggering 44% response rate.  The lesson is that if it’s well constructed and targeted, patients respond to messages on their phones.

iPhone and Android apps stores may have several thousand health apps available, but as yet there’s little integration of any of these into the NHS.  They’re certainly being used by patients, and a growing number of GPs and consultants are suggesting them to patients who might find them helpful for managing long term chronic conditions.  The Wilmslow Health centre’s web site is a good, albeit slightly confused example, listing useful apps for their patients. One NHS trust in Bristol went further and jumped on the bandwagon by developing an iPhone application which gave users information on their local health services and provided a rudimentary electronic health record.  That probably won’t save the NHS single-handedly, but anything that makes people more aware of their health has to be a good thing.

There’s fewer cases of remote monitoring using mobile phones, but that’s likely to change in the next twelve months.  The medical device market is at a point of inflection, where it’s moving from proprietary interfaces to standardised wireless connections, based around Bluetooth and Continua standards.  That is going to have two effects.  It will be much easier to connect devices to phones and thence to medical records, and the resulting competition will bring prices down, turning some of these into consumer High Street products.  Once that happens I’m expecting to see rapid evolution in mHealth applications as consumers become capable of monitoring their weight, heart rate and glucose levels and automatically storing the results on a personal health record.  What will be interesting is to see whether this results in patients sharing data with the NHS, keeping it on their own web record, or sharing it more widely with others who have the same condition.

mHealth also extends to remote consultation, of which the most popular example is the service offered by 3G Doctor, allowing patients to contact a GP when and where suits them.  The advantage of this particular service is the way that it integrates with the NHS.

I used the title “everywhere and nowhere” because there are lots of really useful and productive local implementations of mHealth taking place, but as yet they’re not joined up.  For patients, it means that the technology is arriving in small chunks, often initiated by an individual Doctor or Consultant who’s at the geeky end of the spectrum.  That was confirmed in a review of telehealth projects in the UK in 2008, where Mike Clark concluded that generally they were still pilots of between 5 and 50 users.

For solution providers it means that they need to repeatedly go through the same sales process, convincing another unrelated department of the efficacy of their solution.  As a result, very few of these target more than a thousand users and many are considerably smaller than that, so are still just a drop in the potential ocean of mHealth, albeit very important drops.

We need to be careful about the question of whether any of these initiatives will save the NHS money in the short to medium term.  Many have demonstrably resulted in increased efficiency, as staff have managed to see more patients, have attracted people into the surgery or have reduced wasted time because patients haven’t turned up.  I don’t know of any mHealth application which has resulted in medical staff numbers being reduced, so it is debatable whether the claimed saving are real or accounting subterfuge.

That may not matter.  An important fact about these applications which is often overlooked is that they’re pulling people with diseases, or at risk of disease, into the NHS for immunisations, check ups and earlier diagnosis.  They’re also helping to share patient records, so that treatment is more effective because it’s more joined up.  In other words they’re spearheading a move towards preventative care, with a take-up that is way beyond anything that has been achieved in the past.  It may not save money today, but it is likely to pay dividends in the future.

We need to applaud these pioneers and encourage others to follow suit.  The mobile networks in the UK - Vodafone, O2 and Orange have all announced major investments for mHealth, which are likely to appear during the course of 2011, and which promise to accelerate this deployment.  The reality is that mHealth, even in its simplest forms is already helping to address the future health problems of tens of thousands.  The task for suppliers, GPs and PCTs is to expand that coverage a thousand-fold to bring those benefits to the whole population.

It compares and contrasts the use of remote monitoring technology in the US and UK to support patients at home, both in terms of release from hospital and to manage long term chronic conditions.  Its main conclusion is that the UK is far better positioned to benefit from this than the US.  But there’s one proviso - that the UK needs to put in place a system that allows patient records to be shared between those involved in care, including the patients themselves.

The report acknowledges that this is currently lacking in the UK, but predicts that this will be remedied during the course of 2010 by the introduction on Summary Care Records (SCRs).

Pam’s obviously not spoken to the British GP’s Council.  This week their chairman - Laurence Buckmann, made a presentation to the Local Medical Committee’s Conference calling for SCRs to be scrapped, ostensibly because they require a patient to opt out, rather than opting in.  It’s part of an ongoing campaign against SCRs by the British Medical Association (BMA) that makes Luddites look progressive.  And which seriously threatens innovation within the NHS.

The Summary Care Record scheme is almost always prefaced in the media with the adjective “controversial”.  It’s not because patients find it controversial, but because of a well publicised storm that has been whipped up by members of the medical profession within the UK.  Ostensibly they fear for the security of patient data; their opposition is on the pretext that patients should opt-in, rather than being automatically included, with the option to opt out.  One would have thought that fifty years experience of getting patients to sign organ donor cards might have suggested that this would not work.  Look a little deeper and you see the underlying slyness.  Taking this approach is almost certain to ensure that only a small percentage of the population signs up, so that SCRs never achieve the critical mass to be successful.   It’s a cynical attempt to lobby for failure and to preservation the status quo.  Sadly, the new Government appears to have been sufficiently fooled by these views to call for a review of the scheme. 

Aside from their campaign to delay the project on the basis of security doubts, there’s a steady drip feed of comments suggesting that having accessible records will not provide any benefit.  On the British Medical Journal blog we hear that they are “unaware of any evidence that the SCR will dramatically improve care”.  A well publicised report from University College London reports “no direct evidence of an improvement to patient safety although findings were consistent with “a rare but important impact of the SCR on reducing medication errors”.

The UCL report, sensitively and non-provocatively titled “The Devil’s in the Detail”, highlights that “as of 1 March 2010, of the approximately 8.5 million people who had been sent information about the SCR, 0.65% had opted out. 1.2 million SCRs existed and 14,266 had been accessed.”  It observed that fewer people had registered than had been expected, explaining this on a “clunky” interface and complex registration process.  They failed to observe that a contributing reason may have been a vocal campaign by GPs, backed by the BMA, for people to boycott it and the fact that most local GP surgeries had not signed up, so you couldn’t actually set your SCR up.

Even where SCRs were used they experienced “wicked problems”, (I love the emotive use of words in this report - Wicked Problems is actually a chapter heading), foremost of which was tension over defining what data should be included.  In my experience, SCRs have been hampered by a largely academic debate over what they should contain.  Rather than trying them out and using an evidence base to see what is useful and what not, deployment is being pushed into committee rooms, whilst patients are left with a healthcare system that relies on shuffling mountains of paper around and repeating data inputs multiple times. 

What was also striking in the report, and I don’t know whether this is following practice or not, is the absence of patients from the design, governance and implementation networks.  The report claimed that it initially tried to measure whether the use of the SCR had contributed significantly to patients’ satisfaction, but abandoned this because they found it impossible to judge.  In other words it’s the same old story - Doctor knows best.  And at the point that the patient does get involved, Doctor tells them not to use it.

Once outside the GPs grasp, the report becomes more positive.  Amongst nurses, “the highest users of the PDA device were, unsurprisingly, those who considered themselves confident with the technology and were keen to innovate. The PDA aligned with such nurses’ identity and values (as a mobile workforce, they saw a mobile technology as very appropriate). Working in an organisation where they were not routinely given a simple mobile phone, they felt valued and rewarded when given the more technically sophisticated PDAs. High users of the PDA commented that they felt it increased their credibility in the eyes of the patient, partly because they could show the patient his or her own record at the bedside. It is possible, but only a hypothesis at this stage, that a demonstrable link with the main NHS records system made the nurses seem more a part of the trusted NHS system in the patient’s eyes.”

At that point it’s worth jumping across to the Healthcare at Home report.  Having compared US and UK practice, it concludes that shared health records are absolutely vital to its success.  It’s setting its hopes on the availability of SCRs in the UK to replicate the success in managing chronic disease management that it’s seen in the US.   They highlight the experience of the Veteran’s Association, which has used home telehealth, combined with case management for a number of years.  They’ve seen a 25% reduction in bed days, 20% reduction in admissions and an 86% patient satisfaction rating.  As a result they’re scaling up their approach to reach 110,000 patients by 2011.  (UCL please note - someone knows how to measure patient satidfaction.)

One of the most important messages this report brings back is the need to “Make every interaction count”.  It observes that where there is real benefit, particularly in a fragmented delivery system, such as is case with hospital, GP and social care in the UK, that we move from focussing on the particular function of each professional delivering an intervention to joining the dots, where each intervention can reinforce the others.  That means messages from previous visits can be constantly reinforced to help cement a health regime, whether that’s taking medication, appointment reminders or health measurements.  What they all need is the provision of consistent information, both to the patient and to each health professional they interact with.

Experience from California shows that in a lack of accessible medical information compromises quality and cost, and that the availability of data across organisational boundaries, as well as between clinician and patient, improves care (see the report for references). 

It is difficult to understand the antagonism of the BMA and GPs towards sharing information, other than as an attempt to maintain control of a hierarchy that owes its form to a Victorian Guild structure rather than a modern approach to evidence based medicine.  I think that many nurses understand the benefits.  But the higher you move up the professional chain, the more reluctance there is to accept that the patient is part of the solution, rather than being the raw material of the day job.

Sadly, it appears that the GPs have the ear of our new health minister - Simon Burns.  The Government has announced that they will ring-fence health spending, and it looks as if they’re also ring-fencing the ingrained prejudices of those within the NHS.  I’ve often referred reader to Clayton Christensen’s excellent book analysing the healthcare industry - the Innovator’s Prescription, and I’ll do so again.  He argues that the mix of healthcare professionals we will need in the future is different from the mix we have at present.  We’ll need fewer specialists, those we have will need to be better trained in intuitive medicine in a multi-disciplinary team environment, and that the work done today by general physicians will be taken over by nurse practitioners.

It is telling that in the UCL report, this last group was the one who found most benefit in SCRs.  That should have been an important part of the report’s conclusion.

In conclusion, if you happen to be Simon Burns, or someone who talks to him, or advise him, please realise that we do need Summary Care Records.  If you question why, go out and read the Innovator’s Prescription and then read the Healthcare at Home report.  Don’t listen to what the profession may be telling you - their agenda is one of survival.  Look at healthcare with disruptive eyes and think about the patient.  Ask why a GP has a stronger claim to ownership of that data than the patient themselves?  It needs to be accurate and trusted, but it also needs to be shared.  Patient accessible records are a vital component of giving people the joined-up healthcare system they deserve.  And it might even make it cheaper.

It’s a bit like the case of a child who has hitherto only been allowed chocolate on Christmas Day.  Now they’re being led into a chocolate factory and told they can eat as much as they want.  The inevitable result is a very happy child for a few hours, until they’re violently sick.  At which point they either vow never to eat another chocolate, or learn to treat it in a more sensible manner.

Today the medical industry and energy utilities are being shown the doors of the chocolate factory.  We have yet to see how they behave once they enter it.  Some may emerge as triumphant Charlies, but others risk becoming the commercial equivalent of Augustus Gloop and Veruca Salt.

The first point to address in this new world of data overload is the assumption that we’ll be able to do lots of useful things once we have this data.  There are lots of companies painting a picture of automated homes and lifestyle medical devices based on analysing this tsunami of data, but as yet we don’t know how much can be inferred from it, let alone how we will be able to use it to control other devices.  The assumption that having over a million times the volume of data every year (one reading every three seconds instead of one per year) is going to tell us anything useful is still exactly that - an assumption.  The nightmare scenario is that it doesn’t - it’s just random noise.

I fervently hope that’s not the case and that the data is useful, but to confirm that needs a lot more work.  mHealth and smart energy aren’t the only markets facing this problem - the U.S. military acknowledged it recently, when they said “we’re going to find ourselves swimming in sensors and drowning in data.” We are moving from drawing a straight line through two points to drawing one through a million of them.   At the most basic level, it involves a fundamental change in the underlying business model.  Both the medical profession and the energy utilities currently work on the assumption that if they hear nothing from us, they can ignore us for the next year.  Now they’ll be hearing from us every few seconds.  It’s not just the volume of data that is available, but the question of how to react to it.  That new granularity will show deviations from the straight line, whether it’s raised blood pressure or turning on the hosepipe to water the petunias.  What should a supplier do about it?

In the past, the safe route has been to ignore everything, not least because you don’t known about it, and it will probably have gone away by the time of the next data point.  Once you let the cat out of the bag and tell the consumer that you are monitoring their every move or cup of tea, then they will expect more feedback.  That means more resources on the part of the provider, which is likely to mean more cost.  Where’s the business model that supports that?

It suggests that the industry needs to step back from some of the more complex technology and fanciful gadget push that is appearing in the market and instead concentrate on answering the basic question.  Which is “what can I usefully do with the data”?  That means working with simple sensors that can collect the data, and back end systems that can then aggregate and mine it.  When the UK’s Technology Strategy Board was collecting input for their Assisted Living Innovation Program, I argued that they should do exactly that - deploy ten thousand or more sensors of whatever variety and concentrate on collecting and analysing the data.   I’m pleased to say that they’ve embraced that approach.

It is a critically important task for anyone who is moving into M2M (and that is essentially what mHealth and smart metering are).  You need to start by understanding your data.  Only when you have done that can you start to decide what value it has and whether a large scale deployment is justified.  That justification might be because it makes your business more efficient, it might be because you can offer additional services to your customer, or gain a competitive advantage, possibly by disrupting the market.  Or it could be because a government pays you to do it; but if they do, will they continue to pay the long term, day-to-day operating cost or working that data?

The problem is that you’re unlikely to know the answer to these questions until a year or more after you’ve deployed your first ten thousand devices and collected and analysed that year’s worth of data.  That’s a large initial expense with no immediate return. 

If the resulting business model is customer oriented, rather than profiting from internal business efficiencies, then it needs to include some compelling feedback if the user is going to want to continue to use it.   That in itself is a new area for both the medical and energy industries.  Neither use a language which the consumer understands, at least until the day the bill arrives.  Instead they stick to scientific jargon with BTUs, kWhrs, systolic and diastolic pressures. 

Consumers are far more interested in comparisons - for them these provide the compelling feedback.  That means simple comparisons such as “are we spending more than we were?”, “more than our neighbours are?”, “are we getting better?”, “should I have eaten that extra doughnut?” need to be developed.  None of these are the type of information that these industries have experience with, but if they are going to provide a compelling service they need to take into account customer psychology.  Even when that is done it may not have the desired effect, as evidenced by the recent report which found that when told they are using less energy than their neighbours, Republicans tend to compensate by increasing their energy usage.

To add another level of complexity, many of these comparisons raise privacy issues that are new to these industries.  Comparisons are normally more persuasive when they’re made with a group of peers, rather than just comparing past performance.  But how many companies are aware of what they are allowed to do in comparing an individual against data from other customers?  How much granularity can you use in comparisons with a neighbour?

Some companies are trying to leapfrog the data learning stage by selling a vision to customers.  A good example is Fitbit, who are using thir initial customers both to build their database and provide feedback.  However, for established businesses, which are those that will be supplying 99% of energy and healthcare users, that’s probably not an option.

Equally difficult is answering the question of how often feedback should be provided?  Should it be realtime - “turn it off now”, or after the event?  Should it affect when you are doing something, i.e. trying to change behaviour now, or retrospectively?  Even before we get to schemes such as energy shedding, which will turn off appliances, we need to know much more about the usage models behind data before bringing further automation into the picture.

These are difficult questions, both for new and established industries.  However, the fundamental order remains unchanged.  First you need to acquire the data.  Then you need to understand what it means.  Only then can you determine what that implies for your business model.  Keep an open mind and be flexible in building those business models.  Whether they be improved efficiency, customer retention, Government mandate, future sales through behavioural modification or company acquisition, they all need a company to take the time to understand the data and develop a consistent model.  Otherwise, you may look back and wish that you’d kept chocolate as a once a year treat, and never entered the chocolate factory.

It has all of the characteristics of the next technical bubble, but with the added benefit that, if we can make it work, it might actually save our healthcare systems from terminal meltdown. We need the disruption that mHealth will bring.  As Clayton Christensen points out in his seminal book - The Innovator’s Prescription, the only way we are going to effect a major change in healthcare is through the introduction of new, parallel business models to challenge those that our current healthcare structure is built on.  That will need new technologies that provide more effective diagnosis of symptoms, as well as devices that encourage personal participation in healthcare by putting monitoring and health records into the hands of patients.  Which are exactly the areas being targeted by the mHealth community.

However, there’s an invisible gorilla in the mHealth room that could consign the whole enterprise to history.  It’s called the FDA.  The FDA has the ability to apply regulations that would choke the development of mHealth.  Like all regulators, the FDA moves slowly - far more slowly than the emerging mHealth technology.  It is important for the industry to engage with it to reset the levels of regulation for mHealth.  What is worrying is that most of the noise around regulation is not about that resetting of expectations, but scare-mongering about the possible reaction of the FDA to an expansion of connected healthcare and new delivery methods.  It’s important that manufacturers understand the barriers that regulation might bring, but we’re at risk of crying “Wolf” to the extent that mHealth may never happen, or else only evolve outside the U.S.

Over the last six months, as the mhealth debate has progressed and new consumer applications have appeared on the market, I have seen a worrying trend for regulators to react to this new technology by making noises about the need for them to enlarge their sphere of regulation.  I’ve already argued that if consumer healthcare is to flourish we need a new patient manifesto that does exactly the opposite.  There are positive things happening - groups like the Continua Health Alliance are helping the FDA to understand the implications of mHealth, but that’s not a message that much of the industry is hearing.

Instead, legal firms and regulatory consultants are increasingly talking up the dangers that may exist within the compass of existing regulation.  Its effect is to reinforce the view that regulators are evil tyrants who may kill your business.  It may be implication and surmise, but it’s sowing exactly the wrong message that we need if we’re going to encourage disruption. 

If you’ve been reading the mHealth blogs or attending conferences, you’ll have come across the excellent articles by Bradley Merrill Thompson.  If you haven’t, you need to join some LinkedIn groups dealing in wireless or healthcare.  I’d urge you to do so, as he speaks a lot of sense and probably knows more about the FDA and its attitude to new technology than anyone else.  As well as being eminently knowledgeable, he’s an enjoyable speaker.  He wowed his audience at the recent Continua Summit and had them shaking in the corridors as they jumped at the imagined sound of FDA bogeymen behind every coffee urn.

Like his namesake, Bradley likes lobbing bricks to wake his audience up.  His message is that the FDA’s existing charter is so wide that the organisation could, if it wanted, regulate any device with a medical purpose, or indeed any part of that system.  If that seems like make-believe, it’s not.  It is deeply worrying to discover just how wide its remit actually is, and even more so to learn what its aspirations are in terms of increasing its sphere of influence.

For the medical industry we have today, that’s not necessarily considered to be a bad thing.  As with all regulation, the FDA helps to maintain the status quo, not least by providing a barrier to new entrants.  However, at a point where the industry needs disruption, that aversion to change threatens to stifle or deter innovation. 

To change that attitude, we desperately need to attract new entrants into the industry, as they have the most incentive to lobby for regulatory change.  It’s an approach that has risks - it will almost certainly mean that we let in some of the more dubious ends of the medical spectrum.  But the alternative - maintaining, or even increasing the current level of regulation, will inhibit disruption and lead to a system that cannot serve the changing population demographics. 

I’ve argued that if personal healthcare is to move forwards, we need less rather than more regulation.  A level of dodgy, alternative mHealth may be the price we have to pay if we are going to make serious progress.  And regulators will hate it, as not only will it potentially remove some of their powers, it also means that new entrants, who are not part of the established medical club will try to tell them how to do their job.  But to achieve any of this, we need to persuade manufacturers outside the health sector to come and join in and help put pressure on the regulators.

Experts like Bradley are telling the story as it is, warning manufacturers new to the market of the potential issues with regulation.  However, without any firm signs of movement from the FDA, endlessly repeating the warnings of impending doom sends a signal to new entrants to avoid the market, or at least the US market.   As a result, I worry about the number of companies that are should be thinking about entering the healthcare market, but are putting their plans on hold.  Without their voices, it will be slower and more difficult to lobby for regulatory change.

We need to ensure that message gets across, but that message needs to be used to argue for a reduction in regulatory power, rather than putting the fear of God into potential disruptors.  Otherwise we risk stopping investment and innovation.

Patient centric and regulated medicine currently live at diametrically opposed ends of the regulatory scale.  The patient centric end needs more proponents to push its cause.  There is much that the mobile industries can bring to the table, as their business model is firmly based on being user centric.  They need to be encouraged in their new foray into healthcare and taught how to engage with the regulators to find common ground.  Not worried, otherwise they will put their effort into other ventures.

It is, of course, far easier to live with the limitations imposed by a regulator and make good consultancy income from advising companies on how to work around them, rather than getting the regulators to move to meet the market demand.  As Bradley puts it in one of his presentations “Arguing with a lawyer is like mud wrestling with a pig: after a while you realize the pig actually enjoys it.”  But mHealth needs those barriers to be moved, and to achieve that we need to encourage as many companies as possible to come to the table.  It may be hard; it may take time; but if we just stress the difficulties and dangers we may never attain that critical mass, which may endanger the whole future of mHealth.

Of course, those of us involved with healthcare know that this is more than just an election issue.  The changing demographics mean that the NHS, and every other health system in the world is heading for financial meltdown.  Rather than acknowledge it, our politicians (even those who have been pushing through the U.S. Health reform bill) are doing little more than being fitted for their lemming suits and asking for directions to the edge of the cliff.  We cannot afford healthcare in its present form and we’re running out of time to address that inconvenient truth.

One straw that is invariable grasped and brandished is the potential of mHealth (or eHealth, telecare or eCare) to sweep away the costs.  So in the spirit of helping our flailing politicians, I thought it might be an opportune time to review how it’s doing.

The first important thing to realise about mHealth is that it doesn’t need to be complex.  Much of what can be achieved is through better management of resources and improved prevention.  Back in 2005, the Sunday Telegraph reported that missed appointments cost the NHS £575 million every year.  That’s enough to pay for 27,000 nurses or another 8,000 doctors.  Don’t forget those numbers - we’ll come back to them later.

The obvious solution is to send reminders to patient’s phones.  Back in 2005, a large percentage of patients didn’t have mobile phones.  In the intervening five years that’s changed and companies like iPlato have been successfully rolling out a wide range of these text based services.

A further report was commissioned by mobile phone operator Vodafone, with the research carried out by Tanaka Business School, which was published the following year.  It identified additional savings that could be made by using SMS support services for TB and diabetes sufferers.  The report, titled “The Role of Mobile Phones in Increasing Accessibility and Efficiency in Healthcare” was available at www.vodafone.com/healthcare, until last year, when Vodafone announced its new mHealth initiative, at which point the healthcare section of its site mysteriously disappeared.  You can still find it elsewhere on the net, and it’s worth a read.

At the same time, Orange Healthcare announced plans to launch an SMS reminder service in the UK. Their SMS gateway would also allow surgeries, hospitals and clinics to send out appointment reminders as well as to follow up appointments remotely.  So with the pair of them supporting it, that ought to mean we’re saving our first half billion pounds.

Of course, mobile telephony is such a pervasive part of our everyday life that it worms its way into many other areas of the NHS.  Keeping with the worm analogy, one of the more bizarre savings being proposed is the use of maggots to treat wounds.  Believe it or not, 35 of our MPs, back in the heady days of fraudulent expenses, proposed that the NHS could save tens of millions of pounds by using maggots to eat the dead flesh on wounds, helping to prevent the spread of MRSA.  I’m not sure whether maggot therapy can be counted as mHealth, but we’ll add it to the savings bucket.

Many commentators believe that the management and bureaucracy of the NHS needs to be reformed.  And who better to do it than patients and doctors?  According to Lloyds Pharmacies, a new generation of internet savvy and iPhone toting mothers are dispensing with doctors altogether, diagnosing their little darlings themselves and dosing them up at the local pharmacy.  In the course of which they’re saving the NHS £825 million a year in prescription costs.

NESTA - the National Endowment for Science, Technology and the Arts, goes further and thinks that the mums and doctors ought to get together to redesign healthcare.  Their rather aggressive report on “Patient Designed Services” reckons that this could lead to savings of £15 - £20 billion over the next few years.

Whilst the doctors are busy at their coffee mornings comparing iPhone apps with the mums, there’s a lot to be said for taking care of the remaining NHS staff who will inevitably end up doing all the work.  Last year, an independent report by Steve Boorman outlined how NHS organisations could tackle staff health and wellbeing and save up to 3.4 million working days currently lost to sickness  - equivalent to 14,900 extra staff or £555 million per year.  Once again, a lot of what is suggested can be accomplished by using mobile phones, text alerts and a new generation of simple, connected health and fitness devices.

Of course, they could start off by walking to work.  Not slow to jump on a bandwagon, the Ordnance Survey revealed that it had calculated the benefit of walking.  By promoting walking, they believe that people could tackle their weight issues, reducing the incidence of early onset diabetes and saving the NHS half a billion pounds a year.  Which is timely, as companies like fitbit and fitlinxx are just starting to sell internet connected pedometers - some of the first consumer mHealth products.

Others prefer to look to the automotive industry. After Gerry Robinson sorted out the NHS, BBC radio suggested that we could learn a lot from Toyota.  Back in 2008, they enthused about Toyota’s production principles, claiming they could be applied to healthcare. Compared with Western systems, Toyota’s approach is tortoise versus hare: rather than seeking efficiency by speeding up individual activities, it focuses on improving the flow throughout the whole system, concentrating rigorously on customer demand. The result: a race-winning combination of higher quality and lower cost.   Of course, that came before the recent Toyota recalls, so some might decide it’s safer to avoid the stuck accelerator of medical management and stay at home instead.

The good news is that you can still save the NHS money by staying at home.  A recent report, ‘Hospital care at home’ by Healthcare at Home Ltd and Dr Foster (not from Gloucester), has shown that the free provision of home-based hospital care could save the NHS £1.2bn.  Most of these services rely on remote sensors - either in the form of assisted living sensors, or more critical connected personal monitors.  So mHealth triumphs again.

Of course, this may be too late.  After all, in January 2007, a report from the British Medical Association said that unless the NHS were to undergoes a major overhaul, the Government will be forced to either cut the services it provides or to introduce a partially private system.  Their prognosis was pretty terminal: that the NHS had only a year in which to be saved and that urgent action was vital.  Incidentally, this is the same BMA who last week halted the Government roll-out of Summary Care Records (SCRs) that could be accessed by patients.  Not to save money to save the NHS, but because it was happening at “break-neck speed”. 

Summing up, I’ve done my sums based on all the saving that I’ve come across. And I reckon that if we can use mHealth to achieve all of those savings that have been promised above, it accounts for about £13.5 billion pounds a year.  Which is more than the NHS spends on drugs.

Of course, you have to question how real the saving actually are?  Back at the beginning we looked at the £575 million every year that could be saved from getting patients to turn up for appointments. That’s the equivalent of 27,000 nurses or 8,000 doctors.  It’s a good solid application that is already out there and working, unlike some of the other more fanciful ones.  But if you keep on employing those 27,000 nurses or 8,000 doctors you don’t realise the savings.  You may have made the system more efficient, but with staff costs accounting for around 70% of the NHS budget, the only real savings will come from reducing staff numbers. mHealth may provide the route to achieve efficiencies that allow this, but by itself mHealth will add cost (because it involves additional new services or hardware).  That’s a lesson that politicians and planners need to understand.

That’s my brief manifesto for mHealth and saving the NHS.  Sadly, it’s probably as detailed as anything I’ll hear from this election campaign.  I’m convinced that mHealth is where we need to go, but as soon as it starts delivering its promise, it will require some unpleasant decisions to be made regarding the number and type of medical staff that are needed.  If the BMA thinks SCRs are a problem, they’ve not even noticed the tip of the iceberg.

At the heart of the problem is the integrity of data that goes into a clinical record.  Until recently, data was only ever entered by members of the medical profession.  The advent of accessible electronic health records means that patients can begin to enter their own data or modify their records.  Whilst I believe that’s the way the world has got to move, it raises important issues.

Take the case of Julia…

Julia is fictional - a healthy twelve year old who I’ve made up to provide an example of the problem.  She’s coming up to her thirteenth birthday.  Last birthday, her parents gave her an iPhone which had a personal ICE medical record on it, which allows users to add and edit data.

Julia, like many kids, like vampires.  She’s just been sitting in her room watching a film where the Transylvanian locals are close to exterminating the last vampires.  To preserve their line, the last two vampires cunningly mutate their blood to the previously unknown AB- group, telling each other, as the stakes go through their hearts, that whenever two AB- parents have a child, then their first issue will be a vampire, preserving the species for ever.  (Don’t ask about the science - it’s Hollywood.)

Not surprisingly, Julia thinks this is rather neat, and that it would be cool to update the health record on her phone from Group “O” to Group “AB-”, so that she can show it to her friends at tomorrow’s party and tell them her first baby’s going to be a vampire.  Her application lets her do it.

Walking across the car park to her party, she’s knocked down.  An overstretched hospital believes the information that her distraught mother reads from her phone and forgets the basic pre-transfusion checks…

It’s a rather forced, extreme example, but it illustrates the dilemma of personal health records.  Once individuals can update their records, then the meaning of medical records change.  It’s a fundamental point, but one that tends to get lost.  Patients may do it for perfectly valid as well as more nefarious reasons.  They may want to make changes to affect their insurance, to claim malpractice, to effect a change in their medication, to make their doctor think they are complying more completely with their treatment plan, or simply because they can.  Moreover, the data that comes from connected devices may not be accurate, as it’s unlikely the average person would think about, or even understand the need for calibration.

What’s even less appreciated is that this is only the tip of the iceberg.  Today, it’s a miniscule portion of the population who put data into a health record, or even realise that they can.  That’s about to change.  Consumer medical devices with a wireless link have the ability to push a constant stream of patient measurements into their health records.  It will result in a flow of data that is many orders of magnitude mote than has ever been seen.  And these devices will be freely available in the local mall or internet shop.  How much of the data they generate will be trusted by the medical profession?

The anguish is not just confined to medics who need to act on and have access to medical records.  It’s also affecting groups like the Continua Health Alliance, who were formed to provide an answer to the problem of preserving the integrity of health record data in a connected world.  The core role of Continua is not always well understood.  It came into existence to open up and provide guidelines for the ecosystem of connected medical devices that was starting to appear.  Many people think that its key function is to ensure interoperability between devices from different manufacturers, but that’s just a consequence of what Continua is doing.  Its real job is ensuring the integrity of data as it flows from the measuring device to the ultimate electronic health record.

If we go back to the anxious medics consulting a health record, they need to know that information that has been entered automatically, from an electronic link, is as accurate and reliable as if it had been transcribed by a medical practitioner.  Whilst it might seem natural to think that would be the case, in the connected electronic world that’s not necessarily so.  Whenever a piece of data is sent over an electronic link, particularly if it’s wireless, it may get truncated, compressed or transformed.  If it is accepted by a PC or phone application on the way, it might be converted to different units, averaged, corrected or manipulated in some way.  By the time it has passed through a number of different stages to get to the final medical record, it may have undergone a set of “Chinese whispers“.

The goal of the Continua Health Alliance was to provide an assurance that where each stage of the process conformed to their guidelines, the received data would be unchanged from that produced by the piece of medical equipment.  The Continua logo meant that the path from medical device to medical record was assured.

That is still the bedrock of the Continua promise.  But since Continua was formed, the world of smartphones and apps stores has blossomed.  To trot out an overused cliché, it has changed the paradigm.  Next year, as Bluetooth low energy appears in mobile phones, which enables a mass market of connected health and fitness devices, we’ll see the current trickle turn into a flood. 

Consumer health devices aren’t just changing the volume of data, they’re also changing the way it’s used.  Application developers for smartphone apps are already appreciating this, as they discover that patients have very different display needs to the medic.

Almost every medical device you can buy today displays its results in scientific format, whether that’s blood pressure, temperature or glucose concentration.  They may mean something to many medics - digital displays go well with the white coat image.  But increasingly, consumers are looking for health applications that present results in a manner that relates to their lifestyle.  That may be trends, traffic lights or some other representation, where the original data may not be preserved in its virgin state.  To do that, data is manipulated, and the integrity, precision or accuracy of the original data may be lost.  That doesn’t make this any less valid a health record.  It can be argued, that as it means more to the patient, it’s a better one.  But the question is whether it has the same level of integrity if a medical decision is going to be based on it?

In the coming year, the proliferation of low cost, wirelessly connected, consumer health devices will transform this market.  Much of the data they measure will only ever get as far as a mobile phone, although in time it may get uploaded to patient community sites.  It will generate an explosion in the quantity of patient data that dwarfs anything that exists today.  That makes it a powerful tool for driving evidence based healthcare forwards, if it can be aggregated and mined.

But it may not be, nor need to be accurate. That’s a concept that is very scary to many in the medical profession and medical device industry.

The industry needs to tackle the question of what to how to address this new world, where data may be qualitative rather than quantitative.  It is without doubt a valuable resource, but it is unlikely to sit comfortably in the current medical record mindset.  Continua’s view of end-to-end integrity assured medical record data remains unchanged, but how it will encompass consumer health peripherals for mobile phones.  They have the difficult question of deciding what their logo means on a consumer medical device or application.  Does it imply the gold standard of end-to-end integrity, or a device that connects to any consumer medical application?  Or both?  

The health record keepers within our medical systems face a different question.  They need to consider how to access the value of patient records that may not be derived with the same rigour as they are used to, but which will provide a new order of magnitude of patient data that can help better understand how to manage long term chronic conditions.  It will also be invaluable in driving evidence based medical treatments for them.

Many say the Internet changed the relationship and balance of power between patient and doctor.  That will be insignificant to the change that is coming over the next few years, when patients are able to measure themselves.