YOUR smartphone may be a whole lot cleverer than you think it is. It supports the growing trend towards mobile health (m-health) as part of e-health and an ongoing technological revolution in the wellness arena.
E-health is a term that entered the health lexicon at the turn of this century. Since then, it has become a buzzword on the health scene to cover not just what analysts were calling "internet medicine", but also just about everything else connected with computers and medicine.
E-health has also been described somewhat extravagantly as "not only a technical development, but also a state of mind, a way of thinking, an attitude, and a commitment for networked, global thinking, to improve healthcare locally, regionally and worldwide by using information and communication technology".
Fans of m-health believe it is the logical brainchild of e-health, and the myriad possibilities and opportunities it offers — especially in South Africa, which now has a near-saturation mobile penetration rate of 98%. Although mobile internet connectivity remains relatively low, it is growing, with smartphone imports said to be "rocketing ahead" of ordinary cellphones.
As "health on the go" or "health in your pocket", m-health is a function of the growing use of cellphone technology to revolutionise healthcare on different levels, for both doctors and their patients in both private and public spheres.
In October 2012, the World Health Organisation (WHO) announced the launch of an mHealth partnership with the International Telecommunication Union (ITU).
The initiative is designed to use mobile technology, in particular text messaging and apps, to help combat noncommunicable, chronic diseases such as diabetes, cancer, cardiovascular diseases and chronic respiratory diseases that are epidemic in many parts of the globe, including in South Africa, by helping patients manage their conditions more effectively.
An estimated 36-million people die every year from noncommunicable, chronic diseases in both developed and developing countries alike, according to WHO. They also account for a major share of healthcare needs and expenditures. In the next decade deaths from noncommunicable, chronic diseases in Africa will jump by 24%, the agency forecasts.
In South Africa, the recent launch of FolUp, a mobile and web-based communication application, is extending the concept of m-health as a way to reduce the impact of noncommunicable, chronic diseases and boost general wellbeing in body and mind.
FolUup is the brainchild of Belgian neurosurgeon Dr Geoff Appelboom, who developed the original idea in conjunction with input from hundreds of doctors and their patients. FolUp’s head of operations in South Africa, Simon Spurr, has added local healthcare expertise to the platform.
Removing some of the obstacles
The vision behind the technology, says Spurr, is to help patients understand their health better, get better faster, connect with other patients, share experiences, and to help doctors track and monitor their patients better.
The technology also removes obstacles such as geographic distances and time barriers, he says.
"We have severe challenges in South Africa especially regarding lack of skills, shortage of doctors and nurses, lack of facilities, rising costs of healthcare services etc. Technology has to be the next great ‘enabler’ in healthcare," Spurr says.
FolUp can assist in these areas, he says.
"With more than 20-million South Africans living with a chronic disease — including obesity, which is becoming epidemic — which account for 70% of all deaths, the technology has the potential fundamentally to alter the economics of patient care", he says.
A major problem right now for chronic patients is securely keeping all the data they have in between consultations with their doctor, says Spurr. This includes factors such as mood, quality of life, how they respond to a new medicine, their key vital signs and areas of pain, he says.
FolUp has been developed with an open application protocol interface (API), which means it can integrate a proliferation of wireless medical devices that patients can use to capture key data, Spurr says. These results sync automatically into their FolUp profile, such as data from blood pressure cuffs, glucometers, wireless bodyweight scales, fitness activity monitors, heart rate monitors and other multifunctional medical devices.
"These devices are extremely cost effective, so there are downstream benefits to funders such as medical aids," Spurr says.
Checking the ‘dashboard’
FolUp is designed to empower patients to capture their key metric data, tailored specifically according to their disease, he says. For example, hypertensive patients will capture blood pressure as a priority, diabetics their glucose levels in an easy-to-use electronic platform, using web or mobile technology.
Doctors will be linked to their patients’ profile, and can at any time in turn monitor patients’ "dashboards", an overview of the patient’s health profile that represents key metrics by way of graphs in one central place for ease of viewing, Spurr says.
FolUp is not an interventional platform, though, and will not send a system-generated notification if a patient’s blood pressure suddenly spikes.
"Doctors will not be expected to react to every notification from a patient.
"That being said, if the doctor sees something in a patient’s profile, they can send an instant message via the platform and ask that they come in, therefore driving correct behaviour and consultation," Spurr says.
Doctors can also have their admin assistant pull a patient’s file at any time from FolUp. Patients can print information off their dashboard and take it with them to the next consultation with their doctor, all of which drives efficient consultation, he says.
"It’s all about encouraging patients to track their health, connect with other patients and family, communicate about their disease and share information through access to FolUp’s library of health content."
The technology also offers powerful tools for research institutions and medical associations, Spurr says: doctors can create customised surveys via FolUp to send to patients. They can segment by pathology, he says; for example, five questions to their diabetic patients only. The results can then be exported in PDF or Excel for publishing research. Doctors can also communicate with each other via FolUp, on topics such as peer review of journals, research work etc.
The use of FolUp, via either web or mobi app, is free for both patient and doctor, says Spurr.
In South Africa, the company has had interest from "two large medical aids, medical associations and research institutions"; internationally, FolUp has a large project in the US on the go; in Europe it has two hospitals on board and a large pharmaceutical company has appointed the company for a research study across 22 countries.
He is not able at this stage to say who those connections are with, because of confidentiality agreements.
Privacy and security concerns
Of course, medical apps are proving to have benefits but experts say there are limits and concerns of which users need to be aware. One of those is privacy.
Spurr says FolUp has gone through all the security requirements under the Health Insurance Portability and Accountability Act in the US and South African patient privacy laws, and patients always own their own data.
Dr Aaron Michelfelder, a US physician and professor in the department of family medicine at Loyola University Chicago’s School of Medicine, says other apps might not be compliant with legislation protecting patients’ health information, and this is "especially true for apps that allow patients to e-mail their medical information".
Many diagnostic apps available on the market are also not very reliable, he says.
"I can see these becoming more helpful in the future. Right now, it is best not to use your phone to self-diagnose a problem. But it’s always a great idea to bring any concerns and ideas you have to your physician to discuss in detail," Dr Michelfelder says.
He also sees medical apps as a good way to get young adults and teens engaged in their health habits.
In the US, research shows that children aged seven to 18 spend on average a little more than seven hours a day in front of a screen. There are no definitive statistics on how much time South African children spend in front of a computer or smartphone screen, but analysts say rates are likely to be similarly high.
It makes sense, Dr Michelfelder says, to use some of that screen time to get them engaged in their health, like using a pedometer app.
He warns patients not to download apps that are specific for doctors only, and notes that consumer medical apps are effective only when used in conjunction with a health professional.
In the US, mobile health app developers not surprisingly believe the mobile health field is poised for explosive growth.
By way of evidence for that, they cite surveys showing that:
• Healthcare apps are the third fastest-growing app category for iPhone and Android devices;
• Eighty percent of US doctors use smartphones and medical apps;
• Doctors are 250% more likely to own a tablet than other consumers; and
• Forty percent of doctors believe mobile health technologies can reduce the number of office visits.
On a broader scale, when it comes to public health issues, an international team of researchers, led by Dr Mark Tomlinson of Stellenbosch University’s Centre for Public Mental Health, has been questioning spreading the use of m-health.
Despite the hundreds of pilot studies using mobile health, there is "insufficient evidence to inform the widespread implementation and scale-up of this technology", the team says in a report published in the peer-reviewed journal, PLOS (Public Library of Science) Medicine earlier this month.
The study authors say there are more than 6-billion cellphone subscribers globally, and 75% of the world has access to a cellphone. This has led healthcare providers, researchers and national governments to be optimistic about the opportunities mobile health has to offer.
Scratching below ‘magical promise’
"In some ways, mobile technology has a magical appeal for those interested in global public health over and above the advantages that have been proven with good evidence," the researchers say.
"Part of this magical promise is that mobile technologies may solve one of the most difficult problems facing global health efforts — that of structural barriers to access."
The researchers say that while enthusiasm for effective m-health interventions in sub-Saharan Africa is high, little is known about their efficacy or effectiveness.
"The current wave of m-health interventions are the equivalent of black boxes. Each small entrepreneur or researcher includes whatever bells and whistles that their funding allows in an attempt to demonstrate efficacy."
The authors argue that potential innovative research designs such as multi-factorial strategies, randomised controlled trials, and data farming may provide this evidence base, and make several recommendations for the way forward.
They also say major donors could invest in creating a robust set of standards and a platform that can inform and support local adaptation of m-health applications. The standardised features of the platform could then be available to all local technicians committed to improving the health of their local communities.
The authors believe a global strategy for programmatic examination of the optimal features of the mobile platforms is needed.
Spurr says an app platform such as FolUp is simply "a good way for patients to be actively engaged in and take more responsibility for their own health and wellbeing, and for their practitioner to monitor them better".
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