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October 22, 2012

Making mHealth Happen
By Julie Knudson
For The Record
Vol. 24 No. 19 P. 18

Overseas success stories provide valuable lessons while US entrepreneurs figure out a viable business model.

Statistics indicate we’re in the midst of a global communications revolution. For instance, as of 2011, mobile cellular subscriptions per 100 people are running at nearly 79% in developing regions, with a global average of near 87%, according to the International Telecommunication Union.

Numbers such as these make the rise of mobile health (mHealth) almost a foregone conclusion. In countries around the world, healthcare and research organizations are finding new ways to use the increasing ubiquity of cell phones to improve health outcomes.

Handling Family Matters
A team at Baltimore’s Johns Hopkins University is piloting an mHealth program in Bangladesh that focuses on reducing neonatal and maternal mortality. The majority of births—more than 85%, according to Alain Labrique, PhD, MHS, MS, director of the institution’s Global mHealth Initiative—take place in village homes without the help of a qualified healthcare provider or even a minimally trained birth attendant.

The program is simple. “We asked women to send us a text message notification when they go into labor using either their own or a community mobile phone,” Labrique says. This gives a trained obstetric team the critical time it needs to respond and maximizes the chances of reducing mortality. “We were able, 90% of the time, to get skilled nurse midwives to the home to deliver the baby or to provide postpartum support to the pregnant woman,” he reports.

Besides using the early notification to improve emergency obstetric care and neonatal survival, the system also may allow for better responses to childhood illnesses. “Before mobile phones, we had to wait for days or even a week sometimes to find out that a baby was born in a particular village,” Labrique says. “Now we’re able to know within minutes, and we can target care to that critical window of time, removing important barriers to care through the appropriate use of technology.”

Under a US Agency for International Development grant, Georgetown University’s Institute for Reproductive Health is leveraging mHealth to promote family planning in India. The project, dubbed CycleTel, offers the Standard Days Method via text messaging to help women track and identify which days they are fertile during each menstrual cycle.

While permanent contraception methods dominate family planning in India, CycleTel offers women another option by providing them information on when to abstain from sex or use a barrier method. “We ran a pilot test earlier in the year where we enrolled 700 women to use the service to see if they liked it and if the technology worked,” says Meredith Puleio, MBA, a former program officer and a consultant to the institute. “The research results were really positive.”

Implementing mHealth solutions overseas presents numerous challenges. Labrique says costs—mainly those associated with hardware and bandwidth—often are an early obstacle. In many developed countries, the pipes supporting high-speed technologies aren’t given much thought because they’re reliable, well established, and nearly everywhere. Although mobile connectivity is often excellent for voice and simple data connections, fast Internet access isn’t always affordable in low- and middle-income environments. “The moment you set foot in countries that are not on robust submarine cable connections, you start paying for a very small amount of bandwidth very dearly,” Labrique says.

Even connectivity itself can sometimes be a challenge. Where populations are densely packed, widespread coverage by at least one carrier is easier to find than in more sparsely inhabited regions. “When you go to parts of sub-Saharan Africa, where the population densities are lower, you start to find countries where you have significant pockets of territory that are not covered by any mobile phone carrier,” Labrique says. Although still useful, the advantages of mHealth systems connected in real time are decreased when large subsets of a target population lack wireless network coverage.

Another major hurdle is a lack of evidence around “what’s working, how it’s working, and why it’s working,” says Patricia Mechael, PhD, executive director of the mHealth Alliance in Washington, DC. Past research may have shown a technology’s usability, but solid evidence that a technology has a positive impact on health outcomes is still fuzzy much of the time.

Mechael says some studies are beginning to show that technology can make a difference, pointing to work done by WelTel in Kenya, where mHealth has been effective in helping to improve treatment adherence among people with HIV as well as supporting malaria diagnosis and treatment. “Those are two examples of really good studies that have been published in mainstream public health journals that are starting to point us in the direction of what is working and what ought to be scaled up,” she says.

A Business Model
Once an organization has access to a reliable mobile network infrastructure, understanding the target population is a critical first step. Puleio says the Institute for Reproductive Health team has spent a lot of time in the proof-of-concept phase, largely because the client group and communication structure it first envisioned needed some tweaking. “Even before we developed the technology, we were conducting focus groups with our target audience to make sure there was a need and demand for the service,” she says.

During that process, the team discovered that texting doesn’t always suit the needs of groups with lower literacy rates. “We really had to recalibrate who we were actually targeting. That was an important lesson to learn up front,” Puleio says.

Once the target population had been revised, the institute team fine tuned the content of its messages because “what we thought the messages should be wasn’t what resonated with who would actually use the service,” Puleio says.

Because CycleTel is designed as a service, Puleio says data have been collected about customers’ willingness to pay. “We know women—and their husbands—are willing to pay about $1 a month to use the service,” she says, “so our business model is that it will be subscription based.” However, she adds that eventually the team envisions a scenario where segments of the population pay for the service while others will be subsidized.

While determining a successful and sustainable business model, the Institute for Reproductive Health was quick to acknowledge that its core team didn’t have the necessary expertise to make that assessment. “We worked with a consulting firm to help us develop a business plan,” Puleio says. “It really helped us document a reasonable five-year trajectory of how the service could realistically scale in a sustainable way.”

That plan shows CycleTel can be self-sustaining, but “it would take a certain level of up-front investment from the donors to get us there,” she says.

Each mHealth solution’s focus will influence the shape of its business model. Mechael says consumers may be willing to pay for some platforms but not others. “People will be less inclined to pay for things on the preventive side, mostly because it’s not an issue that’s placing a burden [on] them,” she says. However, solutions focusing on health management may be another matter.

Mechael says one of the most promising business models is based on revenue sharing, where medical professionals within a country can call each other for free while calls or messages sent outside the operator’s medical network are billed to the user. “It creates a brand loyalty, an exclusive relationship with an operator,” she explains, “but it also creates a calling culture among health professionals that then generates additional revenue the operator probably wouldn’t have had without it.”

Jennifer Kent, a research analyst at Parks Associates, says because mHealth covers such a diverse portfolio of solutions, no single business model can be applied to everything in the sector, especially when considering the domestic market. That could prove to be challenging as healthcare providers in the United States look for ways to fit mHealth into the traditional reimbursement structure and application developers determine the profitability of mobile platforms.

“Parks Associates’ data suggests that—for mobile health apps at least—a consumer-pays model will not be sustainable for the vast majority of mHealth apps,” Kent says. “Consumers are generally willing to pay no more than $3 per application, and developers will find it very challenging to deliver quality, effective apps for such little prospective revenue.”

Advertising and other pricing models might be feasible in the wellness and fitness markets, but Kent says it’s still too early to determine how the dollars will work for medical applications. “One strategy among proactive developers is to seek FDA clearance to better make the case to payers that their solutions are serious, quality, effective medical products deserving of reimbursement,” she says.

There may be several business models that initially do not depend on reimbursement. Christopher Wasden, a global healthcare innovation leader at PricewaterhouseCoopers, which recently released a global research study on mHealth, believes the reimbursement discussion will need to be addressed at some point but not necessarily in the early stages. “Business models tend to get adopted at different phases of the adoption life cycle of a new market,” he says.

As the mHealth environment grows, Wasden expects the first wave of adopters to focus on items such as scheduling systems and other solutions that increase operational efficiencies without disrupting a provider’s established practices. “Those mHealth solutions that enhance internal efficiency are paid for by the payers and the providers out of their own pocket,” he says.

Because of the strong return on that investment—not only in terms of more efficient operations but also in decreasing operating costs—reimbursement isn’t necessary to make the case for implementation. Once physicians incorporate mHealth solutions into their practices, Wasden believes the reimbursement model will follow. “[Providers will be] more comfortable providing mHealth in a clinical environment that requires them to change the practice of medicine and get paid different amounts than they’ve been paid in the past,” he says.

Learning From Others
Puleio says much can be learned from the mHealth initiatives under way around the world but stresses that understanding a particular market’s nuances is critical to applying that knowledge successfully. For example, there are significant differences between the needs of developing countries and those in more advanced regions. In the United States, Puleio says there’s often an expectation that technology must be more sophisticated than simple text messaging. However, applying that methodology to other parts of the globe would be a mistake. “Technologies don’t necessarily have to be so complex, and maybe people are better off with really simple solutions,” Puleio says.

There’s a good chance that a fancy application deployed in a less developed region wouldn’t reach the users who need it most. “You really have to know what technology your target population is using,” says Puleio, who believes text messaging has the legs to serve more needs domestically than it currently does. “There are a lot of lessons learned—and projects that are donor funded that rely on text messaging solutions—that could be applied in the US.”

Despite the many differences between mHealth deployments here and overseas, Labrique says there also are striking—and useful—similarities. For example, he points to the use of cell phones as reminder systems to take medications on time. “Nonadherence to drugs is one of the major clinical problems that we face not just here in the US but across the world,” he says. “Human beings are phenomenally bad at remembering to take their medication, and it’s one area where there is increasing evidence that mobile phones have really changed the rate at which we can expect patients to be adherent to their medications.”

The penetration levels of mobile phones, coupled with their always-on, always-with-you nature, makes them good reminder vehicles, Labrique says, “provided we listen!”

The very nature of the US healthcare system may make it difficult to leverage knowledge gained overseas to the domestic market. “I think the major challenge in the US is having a coherent strategy that then enables the various technologies to be better positioned to have an additive impact,” Mechael says.

The decentralization between federal and state levels means different areas have varying IT infrastructures and standards, and while there’s a lot of discussion around meaningful use within the technology community, a master strategy for mHealth is still lacking. “We don’t have at this stage or to the best of my knowledge a good, systematic, overarching plan to aggregate and leverage technology to support health outcomes,” Mechael says.

Complexities within the US healthcare system’s regulatory and payment structure mean that many global pilots won’t translate well to this market, but Kent says there are initiatives being launched worldwide that could be successful on these shores. For example, where many developing markets suffer from a lack of widespread care facilities, consultations via mobile phone help to expand urban providers’ reach to more dispersed populations.

“While the US may not have the same lack of healthcare infrastructure, it can still be very costly for patients living in rural areas to visit specialists typically located in urban areas,” Kent says. “We can use the same telehealth strategies to bring down costs.”

— Julie Knudson is a freelance writer based in Seattle.