Webinar 11/14/11: The Alliance Needs Your Input

Summary response to the mHA presentation (14.11.11).
It is difficult to assess the depth of some of the background information going into much of this presentation – Some comments
Page 10 lists 5 constraints – lack of rigorous evidence; limited technical integration and interoperability; limited sustained funding; lack of capacity; policy changes - but nothing about lack of health priorities and ‘clinical’ integration & interoperability partly related to fragmented biomedical services?
Page 14 cites limited cross-sectoral understanding across fields of global health and mobile
Technology – BUT where is this understanding to come from? this endorses lack of global health overview related to mHealth
Page 15 lack of policy, other priorities, lack of knowledge, cost effectiveness, (all at extraordinarily high levels!)
Page 16 the need for a health service research overview is not addressed by thought leader, researcher, and advisor sector – why? Most OECD academics are involved in fragmented disease-orientated commitments/ applications ‘pushed’ by OECD research and service priorities -Vital Wave and Dahlberg –strategic advisory – offer little insight to health research-service overview.
Page 17 health services research over view not listed in ‘missing commons’
Page 18 who are the people making up this very small sample ‘voting’ over the role of the mHA? Who will be the implementers? More sectoral interests? ‘mHA mission and position unclear’ is unsurprising* but has to be addressed. mHA is vital at this stage of mHealth development – it has asked most of the questions so far. Other wider health leads are absent from the debate.
Page 19 deliver value soon is a stark reality because mHealth could get ‘out of control’ see warning ‘‘danger of being misused with possible harm’
Page 20 as already mentioned the ‘commons’ lack the health services research over view – already identified by mHA in 2010 ‘barriers and Gaps’ but not mentioned here!
Page 21 the community is extensive but incomplete (above). For example, where is WHO innovation? No mention of global health priorities or SDHI? Should have been ‘first item on the board’ at the 2011 Bellagio meeting!
Page 22 there are concrete proposals in here – perhaps the 3-5 research questions to the community may elicit an overview?
Page 23 agree – but the partners are incomplete, or not delivering, on health priorities. It is possible that a fragmented health services community will not have considered the need for an overview of the mHealth potential or where the priorities are?
* NCDs and SDHI are still parallel streams in EC, USA and surprisingly WHO when they address the same issues. This ‘division’ makes forming strategies for mHealth more difficult
Decision makers is often mentioned – who are they and who should they be? – health of nations (global) is a civic responsibility across society – doesn’t this need some attention? Health in all decisions is a step. Some countries, such as Thailand, are pioneers in recognizing this and making the civic changes
mHA, having identified a host of factors – probably unprecedented for a ‘new development in health care’ – now has a ‘big problem’ getting a focus beyond its mission to give it a clear future role and impact. It should also be recognized that most current mhealth applications have come from the extraordinary utility and end-user availability –especially in developing countries – not from a health services perspective.
The ‘state of play’ in global health and the myriad of ‘mHealth factors’ already identified by mHA in 2010 plus (10,14,15, 16,17,19,20,21 above), the urgency for an mHealth strategy to meet its potential to halt the mounting ill-health threatening achievement of the millennium 2015 goals, suggest the need for a strategy outside the box – a lead for global health

Focus and proposal
I will focus one the key points raised by the landmark mHealth Barriers and Gaps- policy paper 2010

1] Absence of Health services research and clinical over view –
Given that WHO and Partners in Health organized the recent Bellagio meeting (Sept 2011) and the call for action – To improve health and reduce health inequalities, rigorous evaluation of eHealth is necessary to generate evidence and promote the appropriate integration and use of technologies
it is extremely surprising that a clinical overview was not forthcoming, to build on a clear question posed by ‘mHealth Barriers and Gaps - Policy white paper in 2010’, based on its thematic analysis of current mHealth usage. One, of many important but wide-ranging recommendations (22) under 6 headings; collaboration, financing, infrastructure, community engagement, human resources, monitoring and evaluation (further endorsing the complexity of this ‘run away’ area of mHealthcare) ; was that

Health research experts from across the globe need to develop a consensus on research priorities in mHealth, in addition to advising on the methodologies, research designs, and metrics that should be employed for future studies.

Why is there no such ‘health’ overview and prioritization on the agenda now? It could be argued that the greatest lack of integration and interoperability is caused by the fragmentation of modern biomedicine and its commitment to curing and not preventing disease (see below)

The relatively recent prominence now given to SDHI and the staggering social and economic costs of NCDs is clearly the greatest threat and THE primary target for global health and especially mHealth – with its high mICT potential and capability as a social equalizer and access route to services – including healthcare. And it is health promotion and prevention that is required –the developing world (nor in fact OECD) cannot afford to spend all its time treating a pandemic of preventable diseases –acute and chronic – repeating the OECD pattern of the last 60 years
NCDs lead to more deaths globally than all other causes combined – striking hardest among the poor. 36 MILLION NCD-RELATED DEATHS IN 2008 80% IN LOW- AND MIDDLE-INCOME COUNTRIES. While those afflicted have to be cared for, it is prevention that is cheapest, fairest, and has a common approach enabled by mHealth. In fact primary prevention and risk reduction can be handled by the same approach – see the world leading Thai cycle of integrated care –which awaits stepping up with mHealth.

There is a remarkably common generic pathophysiological pathway to most of these diseases much more prevalent with social disadvantage within rich and poor countries alike. Even the American Cancer Society, Heart and Diabetes Associations acknowledged this common causality in 2004 – promising a common agenda (of which there seems little sign 7 years later – see their respective ‘lay’ websites!). In the UK NICE (National Institute of Clinical Excellence) has belatedly formulated complex guidelines for SDHI research – but why only for SDHI when these social problems now afflict the majority of western society? While many citizens can choose to avoid damaging lifestyle factors, those socially disadvantaged have little choice – ‘social injustice killing at an alarming rate’ (WHO 2009)

Just in time?
There is a confluence of health service developments, of which mHealth is key, which make up the case for a very different ethical R&D (Institute for Alternative Futures IAF 2005 – funded by Phizer no less) in which the focus becomes health (prevention) and not disease. This confluence includes; a fusion of east-west health sciences to give the health focus; the Electronic Personal Record (not patient); personal health systems (PHS) enabled by mobile telephony to provide for inclusive individualized health (far removed from the RCT EBM advocated today which is not personalized – in fact is too often exclusive for many patients). So beware the evidence base required.

Evidence base and appropriate R&D for future health
In fact mHA, suggesting different research strategies, mentions the use of frameworks. An updated MRC (UK) frameworks guide (2007) for RCTs in complex interventions, includes n of 1 studies to identify individual variation within a group. Hallelujah! a break through to which mHealth can hugely contribute. Action and agile research methods will be highly relevant. None-the-less, modern biomedical care strategy is already unsustainable in OECD countries and is out of the question for developing countries.
Has this confluence arrived – yes almost
Those of us pursuing integrative holistic lifestyle change and practical methods of combining personal biomonitoring with training and education in health promotion and disease prevention, see the mobile phone as the ‘breakthrough technology’ – yet none of this well validated work has appeared yet in mHealth reviews or applications. Why?
Possibly because today’s PHS systems – developed and promoted – by OECD fragmented biomedicine – is linked to specific diseases and even then, with few exceptions, poorly validated - being more about ‘technology seeking an application’ -if 2 decades of EU framework RTD programs are to be the evidence. In fact a recent review (funded by EU!) of the whole EU PHS program labeled a paradigm shift from the traditional hospital-centred and reactive healthcare delivery model toward a person-centred and preventive one – concluded; ‘the products of this research are so misaligned with respect to institutional/ organizational realities and users needs it is very likely that they will never be used’.
mHealth therefore has more than technical integration and interoperability to consider.
Is the ‘clinical’ situation that bad? Fortunately not; while ‘biomedical’ PHS research is foundering (consider also the poor view Frost and Sullivan have on the future PHS marketplace), sports medicine and psychophysiological science has not been standing still. The former have ensured the development of medically approved consumer continuous precision heart rate and activity monitoring – with a robust wireless mobile phone interface enabling unobtrusive interactive 24-hour plus telemonitoring almost anywhere, anytime. A combination with psychophysiology algorithms defining negative and positive elements of lifestyle (stress, activity, diet, drugs) have been developed and evaluated. Training, biofeedback and education (especially in ‘IT-hungry’ children) are now part of a very sophisticated practical economic offering (communities of 31,000 are currently supported by such telemonitoring services). (it is not clear why this ‘work’ has escaped the variety of mhealth surveys)
These systems provide previously unattainable high-level clinical information - psychophysiological research has shown that heart rate variability (HRV)* and activity is a prime indicator of autonomic nervous system function (the primary mind-body homeostatic regulator) – from fetal life to senior citizens - and provides a dynamic response to personal condition –especially when used serially – developing a personal biomarker (exceeding the value of many disease specific biomarkers).
Some of the leading public health advocates of SDHI who stridently criticize the dominant biomedical imagination and its control of 97% of the healthcare and research budgets in OECD countries for contributing to SDHI by providing inequitable access to biomedical care and also attempting to impose RCT-based EB on public health – could now ‘lead’ with advanced public health services research – but with a difference – inclusive individualized research.
The explosion of ubiquity and performance of the mobile phone and its relatively universal standardization [compared to Telemedicine, EPR, PHS (biomedical) – recognized by mHA especially – has accelerated the opportunity for a new applicable affordable ethical R&D for global health.

Is it ready for roll-out? NO - because, again as recognized by mHA, the galaxy of players and stakeholders are unprecedented in any radical change in health care, and they have to be able to participate - learn and contribute to be genuine stakeholders
* HRV measurement and analysis has the benefit of being the world’s most technically and clinically standardized biomarker – and is based on over 150 years of knowledge
There is a chasm to cross – and taking small steps does not cross a chasm

Simulators in health care
Virtual reality has great attractions as safe real-life trainers. Lessons from aviation flight simulation have proved highly successful in training and improving acute care medicine including the processes involved (clinical trials were very quick too). A less well known example, but scaling up in size and complexity, was the simulator used in 2000 before the ‘transfer’ of the largest hospital in SE Asia - Kuala Lumpur General Hospital - to Selayang Hospital the world’s first entirely paperless hospital. Every single ‘user’ from patient, porter, administrator to neurosurgeon trained in a 4 story simulator for 1 year before the switch and opening day. Notably every technology and service supplier had to provide fully working systems – some failed – many were modified. Not only was the transfer very successful – but an extraordinary number of changes in practice were made – on-line data – corrected old practices and EBM. A recent report in NEJM from Stanford shows how an accessible EPR has advantages over EBM and experience for individualized care.

IIC-WS – Inclusive individualized community-wide simulator with a difference –
‘thinking big but inexpensively and inclusively’
Since an exceptional number of disparate radical ‘outside-the-box’ innovations (disruptive technology), aimed at infusing a unifying socially-inclusive wellbeing and health practice across the whole community, need to be evaluated in parallel, ‘national’ IICWSs are proposed for evaluation and successful implementation of ‘health for all’.. This proposal takes mICT-enabled simulation and ethical research and development into ‘whole’ communities for the first time. It is suggested that there be one in each WHO region (6) for communities of 250,000* chosen for its cross section of SDHI reflective of the nation –ideally there would be urban and rural sites.

Summary of the proposal
It fulfils a futures health scenario by placing, sharing and unifying the engine-room of medical science within the community enabling civic participation and responsibility ‘across the board’ starting with inclusion of all citizens. Clearly major improvements to health inequities (HI) can be made by rectifying SD factors – but is that enough? Some important factors (e.g. housing, income, work role) cannot be changed in a useful time frame and it seems clear that understanding and reversing lifestyle illnesses, especially SDHI, is not simply improving social behaviour – diet and exercise important as they are. However, more seriously, biomedicine is also currently unsuited to the task.
* 250,000 needs detailed discussion – being large enough to have significant samples of the significant diseases and manageable by the mICT technologies now available. All 250,000 need to be involved!
A revolution in seamless integrative research and care is urgently required for biomedicine and especially health promotion and disease prevention (SDHI) – located in the community generating a new evidence base
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The beleaguered EPR, Telemedicine (rapidly becoming a part of mHealth), and PHS development will work in a comparatively small environment and their full role will be established
International endorsement (e.g. WHO. mHA, health unbound) would mean that a regional and national focus would get everyone’s attention – from citizen to government and importantly all technology suppliers. It could achieve near zero costs because of its role as a pilot site for ‘health for all’, simulator and test site. Importantly it would deliver essential rollout information quickly. Serial measurement* means ‘action’, ‘agile’, framework answers. As mHA also proposed, a sharing ‘non-competitive environment’ would be highly desirable – especially for industry and academics. Global health desperately needs this.

Of course, health and wellbeing does not occur in isolation and an ideal IIC-WS would include a wide range of cultural and educational opportunities

This ‘simulator’ is not an alternative to most of the mHA tasks identified, but should be run in parallel with the huge task of standardizing, harmonizing and rationalizing the highly innovative mHealth applications burgeoning in community spaces where there was nothing. However, a hierarchy of mHealth applications geared to global health priorities would be one objective – tomorrow’s mPhone will have unbounded capability.

The presentation highlights the lack of strong evidence to support that MHealth innovations can improve patient outcomes. To support the implementation of clinical trials, we need the buy in from clinical partners. How is the alliance going to improve the collaboration with the clinical partners?