Mainly mHealth: a few predictions for 2014, and some speculation

Editor Charles on what to watch for in 2014

As we have covered previously (and here), there’s no shortage of forecasts that the mHealth market will continue to grow faster, or of penetrating comments like that that won Research2guidance a What in the Blue Blazes award that smartphone user penetration will be the main driver for the mobile health (mHealth) uptake. mHealth apps continue to proliferate – there’s even shortly to be a Pebble apps store. There are a few straws in the wind that not is all well though – for example, as we covered recently, Happtique ceased, at least temporarily, its apps approval process, citing security concerns.  Elsewhere Fierce Mobile described serious data privacy issues with the iPharmacy app, and the ICO recently produced security guidelines for app developers in the UK.  The EU is also strengthening data privacy, moving from individual country directives to a pan-EU regulation. This leads us to our first prediction :

• Security and data privacy issues will become a serious mHealth issue in 2014; developers failing to take great care over security and privacy issues will risk very adverse publicity and worse.

Another issue with mHealth apps is the lack of evidence of efficacy (an issue I have been working on for the past three months on behalf of the TSB/dallas programme – I will be describing my recommendations in Telehealth & Telecare Aware very shortly), as evidenced for example by this Med City News item and this Healthcare Technology Online item.  This Computer World item and this mHealth News item also make the point strongly that there are lots of bad apps out there, a comment seriously underscored, for example by Dr Richard Brady’s paper on opioid converters that showed a 15x variation in results between different mHealth apps.  This leads to our second and third predictions:

• Unless steps are taken quickly to ensure that doctors cease using uncertified apps, there is a high probability of use of such an app being implicated in the injury or death of a patient in 2014;
• Growth in use of mHealth apps will only really take off once patients and doctors can have confidence in their efficacy.

The process of obtaining and more importantly, retaining, CE certification for mHealth devices that are considered ‘medical devices’ (again keep watching Telehealth & Telecare Aware) is non-trivial, and to demonstrate good efficacy will also require significant expenditure on evidence gathering, as well as ingenuity to get results quickly.  Even satisfying the requirements of ISB 0129 for assessing clinical risk, used by the NHS Apps Library for apps that constitute a risk although do not meet the definition of a medical device, is onerous. A related issue is how organisations are going to realise real benefit for patients from all the data they will be receiving from mHealth apps; even supercomputing is in consideration.  This led Adam Darkins at the RSM November Telemedicine Conference to suggest that substantial organisations with good knowledge management expertise would begin to move into this space, as this item, and this item describe how IMS is. The combination of these two trends suggests our fourth prediction:

• Marketing and sales of serious mHealth apps will, as with pharmaceuticals, increasingly become the province of large companies able to afford the expertise to obtain evidence and to analyse fully data received.

Another interesting trend we covered in 2013 was recently highlighted by the ATA’s decision to accredit online medical services.  Clearly, patients are increasingly happy to consult doctors remotely, as a recent Intel survey of people in eight countries showed.  As we reported in October, American Well had introduced such a service.  At the recent mHealth Summit, Andrew Watson MD, went so far as to say: ‘I don’t know why patients come to see me’. A Swiss study has made recommendations on the most effective ways of carrying out remote consultations too. The 3G Doctor rightly pointed out that remote consultations suited many GPs too. There was even a cry in Pulse this month by Dr Tony Copperfield bemoaning the passing of the remote monitoring DES as a lost opportunity to keep patients out of the waiting room.  This leads us to our fifth prediction:

• 2014 will be the year when remote consultation between patients and doctors becomes accepted practice.

So to the 3D printing spot – not really mHealth, in fact not mHealth at all, however it is a regular feature of our posts.  As we reported recently, also here, and especially here (there is more, including the light-hearted) the development of 3D printing for bone, skin, organs and other body parts is progressing fast.  Most recently On 3D Printing reports that having printed a small liver this year, Organovo is planning to print a complete human liver in 2014, and that a ‘biopen’ has been developed that enables surgeons to “draw bone, skin, and muscle tissue”, literally, on patients. Whence our sixth prediction:

• 2014 will be the year when the use of 3D printing for medical purposes is taken seriously by clinicians.

Finally mHealth is, at least in part, dependent on the mobile devices used to deliver it.  At the up-coming “Recent Developments in Digital Health” event at the Royal Society of Medicine on February 27th 2014, Dr Chris Elliott of Leman Micro Devices is hopeful of being able to demonstrate the next generation of smart phones that, with the touch of a finger on a pad on the device, will measure blood pressure (systolic & diastolic), SpO2, pulse & respiration rates…and measure body temperature when held against the forehead.  When those start becoming available on the high street, and certified apps are developed to use the information generated, perhaps the RCGP will finally abandon its vision of the GP in 2022 where the only significant technological change over practice today is seen as remote delivery of test results?  This leads us to our last mHealth prediction, that:

• The growing availability of vital signs measurement capability on ordinary smartphones will begin the transformation of the doctor:patient relationship in 2014.

…which prompts a few thoughts about how far the role of doctor will change over the next decade.  Watching clinicians over many years, their activities seem to fall into the following:

1. observing, including physical tests such as blood pressure, ECG, EEG, X-rays
2. making chemical tests on fluids & tissues, such as for blood sugar, INR, troponin, BNP etc.
3. accessing vast professional knowledge, to diagnose and determine appropriate treatment for the condition diagnosed.

Of these, clearly technology has vastly aided both the first and the second – high-end ECG machines are now said to deliver more accurate diagnoses of heart condition than most cardiologists, and doctors no longer have to taste urine to see if someone is diabetic.

Regarding the third, there is a growing recognition that ‘the singularity’ is near, when machines think faster and better than people, as for example any reader of Ray Kurzweil’s excellent books will be aware.  It’s hard to believe that a process as logical as clinical diagnosis will not be helped by increasing computing power (which in turn is likely to become more ‘intelligent’ as the EU’s Human Brain Project and its brain-mapping counterpart in the US begin to unravel the mysteries of how the brain works); after all much of the diagnostic groundwork, in systems such as Isabel, already exists. And just think too, what correlations a single system overseeing the treatment of tens of thousands of people, with access to regular vital signs and other information on progress for each one of them, might be able to spot to enable it to improve patient care, that elude the best of GPs treating far fewer. Doubtless increasing genomic analysis & knowledge will enhance this too.

Not certainly a prediction for 2014, however I do wonder what role GPs will be predicting 9 years hence in 2022. The BBC quoted Sun Microsystems Vinod Khosla as making the “extraordinary” claim that in the future 80% of what doctors do will be replaced by technology. Sure there will be mistakes made, and we will have to get used to recognising that machines, like humans, are fallible, just as long as the trend in mistakes is to less than clinicians currently make now.  As someone who has suffered from a couple of major medical blunders and a goodly number of minor ones in my life, it’s hard to see a machine doing worse…and the thought of getting routine medical attention shorter than the one calendar month I recently had to wait to see my GP is most enticing.

And finally, one hope for 2014 – a major UK politician will be brave enough to support a local hospital closure and make the case to the electorate that fewer hospital beds can be good.  If we are to use technology to treat people where possible in their own homes, where they want to be treated, and away from hospital-acquired infections, then the funding needs to be redirected away from secondary care, as the Danes have been doing so heroically, and the University of Pittsburgh Medical Centre, for example, is assisting in the US.

Do you agree or disagree with the above? Is there something we have left out? Perhaps you have a prediction on Google Glass usage or other wearables in 2014 for example? Do post your comments.