The 3^rd Annual mHealth Summit, held December 507 in Maryland, was sponsored by the Foundation for the National Institutes of Health (FNIH), in partnership with the Health Alliance, mHimss and the National Institutes of Health. It has been billed by the executive director of FNIH as the single largest mobile health event in the world and the conference functions as a “global convener of the mHealth ecosystem.” (Campbell, S., 2011)

Attending this conference as a nurse-practitioner student and PhD research fellow provided me with two different lenses in which I reviewed the “mHealth ecosystem” as presented via the specters of the following Session Tracks: Business, Research, Policy, Technology, mFinance, and HITX.0

Dr. Patricia Mechel, PhD, lamented that “…the mHealth field is fragmented and silo’ed” (2011). In what way is that surprising given our current Healthcare operational apparatus? Until Centers for Medicare & Medicaid Services (CMS) stands up to apply “meaningful use status” to a decent array of health tracking mHealth apps, and subsequently signals the functionality for mainstream primary care interface between this new data source and providers, the products (apps, websites, biometric sensors and tracking tools) will continue to be designed, developed, and produced ad nauseum. Hopefully, the products do not peak and burn before the time is right to get into the “real” and reimbursable healthcare scene.

The next to deliver the opening remarks was Dr. Richard Kaplan, from OBSSR and the NIH. His call for focus was on behavioral modifications to combat the “…63% of global deaths attributed to non-communicable disease”.  He alluded to an advanced use of “…sensors and monitors, portable and affordable diagnostics.” However, nurse researchers take note: Dr. Kaplan also warned of the need for “…systematic, impartial investigation to document the consequences of mobile health” (mHealth Summit, 2011). He stated that part of the National Recovery Act included funds to build a national platform with interoperable standards. Government’s role, he continued, is fourfold: (1)“…providing the research to develop context for new (private) technology innovation…” (2) Encouraging health information exchanges, (3) providing states with resources, and (4) incentive payments to offset primary care providers’ costs to transition. He was the first of many to insist on the “meaningful use” of adapted technology to “track outcomes in a meaningful way”. He announced that the government is making all data known to them on mHealth available at www.healthdata.gov.

Down the hall, HRSA director Yael Harris, Michelle Lim Warner of CMS, and Julie Knapp of the FCC discussed opportunities for both private and public innovators to take the concept of “mHealth” and take advantage of the greatly increased mHealth research grants available since the passage of #PPACA. “Beacon communities”, impoverished communities who have received multiple interventions with mHealth initiatives, have been providing data to support the meaningful use of mHealth. However, when pressed by an audience member, CMS spokeswoman Ms. Lim Warner, dismissed any thought of imminent payer reimbursement for provider use of mhealth apps as being premature, stating that we need yet more of an evidence based data supply before we approve their use on large scale Medicare/Medicaid level. Thus, the frantic, quick-to-finish line product development will continue.

In following up on the CMS and HRSA announcement of this competitive development initiative, I located the “mecca” of available, government funded grants , called challenge.gov, which focus on crowdsourced solutions for multiple societal problems, from  developing a transit app in New York to developing a HP2020App that challenge developers in the following proposal:

The Challenge

“Developers and public health experts are expected to co-design an application that makes health indicators customizable and easy to use.  Successful applications will make it easy for users to use the Healthy People 2020 Leading Health Indicators (LHIs) and mash up data in meaningful ways. Some topics of interests are :

• Community, county, and state health status comparisons
• Data from electronic health records to assist with case management
• Real-time communication tools to stay in touch with peers
• Educational curriculum to teach health promotion and disease prevention
• Related news, analyses, and blogs from outside resources
• Related community-level data, combining with the LHI data in innovative ways
• Access to social media outlets and online networking communities

Co-Designing for the End User of the App

How can your app make a difference?  The graphic matrix above provides numerous combinations of potential brainstorming scenarios that might help you get started.  Pick a Person, a Place and a Leading Health Indicator and get creative.”  (http://challenge.gov/ONC/255-healthy-people-2020-leading-health-indicators-app-challenge).

This is a great place for Nursing professionals to meet and collaborate with the technological side of app development. The requests for submission are straightforward, as well. In fact, it is terrifically simplistic to the point that if we do not encourage emerging nursing professionals to engage in this level of development, many private, for-profit stakeholders will. It should be our professional field and allies who develop mHealth tools that collect “wishlist data” as it has been called- tools that indeed are meaningful and help the provider track and trend along with the patient. Who better than a Nurse Practitioner (NP) to co-develop these products?

Much media attention has been given to physicians and their stance on mHealth.  During the 2011 mHealth Summit, hundreds of press from around the world sat in on the multitude of presentations, noting over and over again the questions regarding “physician appeal”, “physician usage”, “doctor’s visits”, etc. While there is a vibrant and important debate regarding the lack of “push” regarding physician input into health apps, there was complete silence regarding the need for push from other practitioners, such as FNP’s, to make similar demands. Nevertheless, the discussion regarding the medical community’s role in the “push” and “pull” of mHealth is extremely relevant, and if Nurse Practitioners do not begin to adopt the same tenacious love and welcome of technology that physicians have, we will once again be left trying to define our practice in the absence of presence at the dawn of a new healthcare age.  The following link is an example of the discussion regarding physicians’ need to be involved in the selection of patient-centered apps.  http://www.healthcareitnews.com/news/doctor-or-patient-who-will-drive-mhealth

This discussion must also concern the definition of the “user” of mHealth.  Consumer or patient? Customer or client? Individually chosen or insurance-based mHealth apps.  In the end, all stakeholders at the mHealth Summit are concerned with the road ahead.  Will insurance begin to require, or at least reimburse, for ACA’s and other groups who utilize best-practice apps to manage their patients’ home-based healthcare data?  What kind of data do practitioners need? Is this a drive to quell fear about the lack of practitioners forecasted for future years?  Rick Scully, Senior Healthcare Manager of nPHASE , a Verizon Wireless/Qualcomm venture, succinctly described the high ratio  of product designers in contrast to the low ratio of medical and nursing professionals at the Summit: “It’s the same old story…mousetrap engineers pushing these solutions.  What I want to know is where is the pull in this whole thing? mHealth is not a toy, we need to keep in mind the MD and NP focus” (Scully, personal communication, 12-5-11).

Indeed, the push from developers is decidedly stronger than the pull from providers as long as the FDA and CMS do not move along the usability of the class of apps available at Android Market and iTunes.  mFinance, as Rosemary Nelson, RN, Taskforce Chair of mHimss reported in the opening remarks, is furthest along, because it does not have to wait for products to be approved on a grand CMS scale before it begins to pick economic winners in the private market.  The danger here is in the lag time presented and expected to continue for the next few years at least, providers are not the ones being courted, addressed, assessed and involved ultimately with the spectrum of mHealth apps on the market. Instead, the products are incubated quickly, in places such as Harvard Business School’s Incubation Lab, The mantra “Pick a Person, a Place and a Leading Health Indicator and get creative” was displayed ad naseum in the Exhibition Pavilion, where over 300 mHealth companies displayed their cyber wares, ranging from MyGlucoHealth Wireless Meter (an FDA-approved glucometer which wirelessly uploads to a secure clinician-monitored online portal) to the NIH Office of Dietary Supplements (ODS), who has created an app that enables patients to track their dietary supplement use and easily share the information with their healthcare provider with an app called MyDS (available at http://ods.nih.gov). While many products were intriguing, healthcare providers (HCP) are still in the majority out of the loop when it comes to their use, since direct-to-consumer applications are not mandated for reimbursement.

During a packed mHealth conference entitled “Chronic Disease Management: Heart Disease”, Anthony Sterns of iRX Reminder LLC, and professor at Kent State University, reviewed his iPad based intervention for patients selected from a TIA population in a stroke-floor of regional hospital. The main theme of his presentation was the concepts of “adherence and retention”. The patients were screened as eligible to participate ONLY if they could mentally and physically pass a 45 minute training session on iPad. This process is called the “use-test”. Thus, all patients were able to access and comprehend the tools promoted, which included setting an alarm clock for medication administration, keeping a log on physical and behavioral choices set up remotely by the experiment designer (and envisioned to be set up by PCP and patient together in real practice). Such programmable behavior prompts will be used to encourage the best compliance in patients’ with deficient memories, or busy schedules or a host of reasons why they may not commit to daily regimen with simple, passive retrospective monitoring.

Sterns twice described the smart phone as a “cognitive prosthesis” which improves patients’ self-images as more “competent”. This theme was carried along as Sterns discussed the three theories that were used in his TIA Smartphone intervention: 1. Wagner’s Chronic Care Model (which ties in to the creation of an app to optimize the self-management of chronic illness with the most informed and prepared patient), 2. Lawton’s Environmental Theory (1991), which rather than taken traditionally to describe physical limitations, has been used in this app-intervention in relation to cognitive limitations (hence the term “cognitive prosthetic”). Finally, the 3^rd theory used in the study was Bandura’s theory of empowerment.  Sterns said that “…giving a set of behavioral choices…reinforces the behavior. The smart-phone is the ‘single-point-of-action…” to deliver the behavioral choices. (mHealth Summit, 2011).

Data gathered during the TIA intervention included attitudinal data, behavioral data, physical data and medication-adherence data.