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tmj20109990lowlink v03 by sbepstein



mHealth: The Next Generation
of Telemedicine?

   C. Peter Waegemann is the Vice President of mHealth Initiative                  process of democratization that has happened rapidly and has placed
Inc., a Boston-based not-for-profit organization promoting mHealth                 our society on a distinctly different path compared to both expec-
applications nationally and internationally. Until February 2009 he                tations and intentions. It is becoming more common to check out
was CEO of the Medical Records Institute, a Boston-based organiza-                 online reviews of books, hotels, restaurants, and many other items
tion involved in applied research and functioning as an educational                before buying. But, the role of the movie critic or book critic has been
clearinghouse, as well as the Executive Director of Center for Cell                replaced by reviews by those who are known by us to like or dislike
Phone Applications in HealthCare. Since the 1980s, he has been a                   the same books (or movies or whatever) that we like or dislike. This
visionary and promoter of electronic medical record systems (EMRs).                move from expert opinions to personal but public discussions is also
Twenty-five years ago, he started the annual conference Toward an                  starting in healthcare. In addition, new Smartphone capabilities,
Electronic Patient Record that each year drew several thousand at-                 from stethoscope functions to camera and video and more, provide
tendees. Waegemann was one of the first to define the distinctions                 new opportunities for clinicians. New voice, text, and image trans-
among EMRs, personal health records, and electronic health records.                mission capabilities are paving the path to communication-based
Several years ago, Waegemann became convinced that cell phones                     healthcare. The book is being replaced by the e-book for the book
would become a major tool in healthcare, and he is the former chair of             reader, and the medical book is being replaced by the application
the Mobile Healthcare Alliance. He is considered an international                  (app) or device that clinicians are holding in their hands.
leader in medical informatics with a special interest in electronic                   Connecting healthcare providers for patient-centric care and pro-
patient record systems, standards, networking, telemedicine,                       viding remote patient monitoring and treatment have been the core
mHealth, and the creation of the national information infrastructure.              activities toward a connected health system. However, interopera-
He is the most sought-after speaker on electronic health records,                  bility has been a moving target, and decades of standards efforts and
e-Health, and m-Health, and in 2007, he was cited by HealthLeaders                 systems work have not helped much in improving the situation.
as one of 20 outstanding people in the United States who make                      Images can be transmitted and integrated into receiving systems,
healthcare better. He is designing mHealth Initiative’s new mHealth                but context-related text is still causing interoperability problems
Networking and Web Conference as the central information place to                  between two or more systems. As systems are moving to a ‘machine-
learn about mHealth activities.                                                    to-machine’ mode, simple connectivity is no longer adequate.
                                                                                   Furthermore, new security methods allow encryption-based safe

           ew developments are shaking healthcare at its founda-                   transmission of information via the Internet, costing a fraction of
           tions. The old vision of telemedicine—often described as                telemedicine over dedicated lines. When the new phenomenon of
           connected healthcare—is giving way to communication-                    mobile communication and computing devices is added, completely
           based health based on a number of new factors such as the               new communication systems and rules emerge.
availability of Internet resources, new low-cost connectivity, dif-                   Mobile devices have had the fastest adoption of any technology
ferent communication patterns, and a healthcare system that is be-                 in human history. They offer low-cost communication that can be
ginning to be restructured. Within a few years, the Internet morphed               safe. Today, mobile phones have a tremendous impact on our society
into Internet 2.0 and 3.0, changing our society in disruptive ways.                and our lives. One can label a segment of our population as ‘‘mobi
In the process, the Internet not only became the trusted source of                 persons’’ who use their phones for a multitude of applications from
information (with some reservations, of course) but also enabled a                 banking to Global Positioning Systems, from entertainment to yoga.

DOI: 10.1089=tmj.2010.9990             ª M A R Y A NN L I E B E R T , I N C . . VOL. 16   N O . 1 . J A N U A R Y=F E B R U A R Y 2 0 1 0   TELEMEDICINE and e-HEALTH 1

This is in addition to the mobile phone being an electronic key or        not want to be overwhelmed by hundreds of e-mails per hour. Easy,
identification device, a communication device for voice, text, and        intuitive e-mail systems of ‘‘medical grade’’ are still not easy to find,
e-mail, and the source for just about any information one seeks.          but easy teleconferencing and digital networking systems are
The Internet and mobile phones separately or in combination offer         merging to create a new kind of ‘‘group consultation.’’ Another form
new telecommunication options that are easy to use and very cost-         of networking consists of specialists exchanging information on
effective. Although not quite yet appropriate for detailed images,        specific medical topics. An example is Brain Talk, a group of neu-
new methods such as projection from the mobile device might offer         rologists discussing experiences and cases. These applications are in
surprising high image quality at low cost.                                addition to traditional telemedicine and are replacing some of the
   In turn, communication patterns must change for better care.           legacy applications. Interactive tracking of assets or patients is also
Patient empowerment has given way to patient participation.               a new building block that has to be included into the mix.
eHealth, the use of health information and communication technol-            Consider another aspect of telemedicine: remote patient moni-
ogies, is slowly being replaced by fundamental structural changes in      toring. The capture of vital signs, monitoring of a patient’s health
healthcare, such as the advent of new care and communication pat-         data, and remote interaction with the patient have been proven to
terns. The goals of such new communication patterns and systems are       have a positive effect on the cost of care while maintaining, and
(1) making the scientific body of medicine available to clinicians in     sometimes improving, its quality. However, instead of traditional
decision-supporting format, (2) facilitating communication between        wiring for remote patient monitoring and treatment (RMT), a wide
patients and clinicians outside of the traditional visit, and (3) en-     range of apps are now available on mobile phones. Remote moni-
abling new communication among clinicians (medical networking).           toring can be done with low-cost systems. Devices can interact, and
   Medical schools are experimenting with having clinicians and           systems can be integrated with various intuitive and user-friendly
students seek resources on Smartphones.* It is not clear how many         software. Additionally, ‘‘smart house’’ developments offer such
physicians are using such resources in daily practice, but it is an       communication as part of the package, and some vendors are moving
increasing phenomenon. Add to that the fact that patients are using       into the arena of care coordination. In other words, RMT today is also
the Internet as a source for further wellness and healthcare advice.      very different from earlier versions.
Recent reports show that more than 70% of patients are using the
Internet as a second opinion.** A wealth of ‘‘personal software’’ is      Evolving New Generation of Telemedicine
emerging to assist patients in managing certain aspects of their             For the next generation of telemedicine, new approaches must be
health. mHealth Initiative’s research has shown that in October 2009      implemented. However, there is a growing consensus that technology
there were almost 1,000 apps on the iPhone alone for consumers            implementation alone is not the answer. New technologies have to go
and patients.þ Parallel to these developments, new communication          hand in hand with behavioral and structural changes in healthcare.
patterns are emerging that make the visit (encounter) secondary,          The move from a doctor-centric to a patient-centric healthcare sys-
placing communication by mail, text, and voice in first place. In other   tem can best be described as adding different participants to the care
words, rather than communicating for a few minutes every few weeks        process and moving the center of care away from the physician’s
or months with a provider, a patient reports symptoms, pain, and          office (or clinic, hospital, or other provider setting) and toward the
other observations when they occur in order to allow the healthcare       patient. Can the future role of the physician be compared with a
professional to recognize and respond to trends and influences that       conductor of an orchestra who is depending on the exact execution of
might not otherwise be apparent. The work of Project Health Design{       the work of all participants? Contrast this with the image of a phy-
on patients communicating and clinicians managing Observations            sician being isolated in his office, not knowing what colleagues are
of Daily Living is groundbreaking. Of course, such systems require        finding, considering, prescribing, or deciding for patients. From the
a new communication management system, because clinicians do              physician’s perspective, the involvement of patients and others leads
                                                                          to ‘‘participatory medicine.’’ However, this process is already going
                                                                          one step further toward ‘‘participatory health,’’ which involves all
*As reported in the Washington Post, May 19, 2009.                        wellness and care providers as well as patients. Participatory health
**Pew Institute.                                                          assures that all of them have relevant information and contribute
  See                   to the patient’s health dashboard, enabling them to provide the best
 Supported by the Robert Wood Johnson Foundation.                         wellness and health care. Such ‘‘orchestrated healthcare’’ will be

                                                                                    mHEALTH: NEXT GENERATION OF TELEMEDICINE?

only partly conducted in the physician’s office, clinic, or hospital,              and implanted and wearable devices for information capture and
with much of it occurring in the new ‘‘wellness- and healthcare-                   monitoring.
communication space.’’ The consumer=patient is at the center of this                  The mHealth movement is worldwide. In some countries such as
personal health Web and controls access, dissemination, and privacy                Brazil and India, health systems can leapfrog to advanced mHealth
issues. This new healthcare pattern requires structural changes in                 systems. In Africa and some Asian countries, basic mHealth can
healthcare as well some new ways of reimbursement (reimbursing for                 provide much-needed basic care that is otherwise not available at
research and e-mail, for instance). Such a participatory health system             all or only with great limitations. Mobile phone technologies have
will be enabled by new communication patterns based on two pillars,                changed the lifestyle of the younger population in Europe, North
i.e., advanced Internet and mobile device communication.                           America, and some other countries. There are indicators for the
                                                                                   convergence of these new communication patterns with some re-
                                                                                   structuring efforts in healthcare.
                                                                                      As exciting as these developments are, one must not forget the
   If we want to be ready for the new generation of healthcare, we
                                                                                   hurdles and potential downsides. Security and privacy issues need to
need to let go of outdated visions of telemedicine and a health system
                                                                                   be resolved. Systems have to become more intuitive and easier to
that is ‘‘just’’ connected. We need to discard any ideas of Telemedicine
                                                                                   use—think of doctors having to use small keys on Smartphones or
1.0—expensive, dedicated connections that do not fit into the new
                                                                                   touch keyboards. However, in the near future, new devices and sys-
world. A new technology platform is available that is very different
                                                                                   tems are expected that may help the mHealth revolution to reach
from traditional telemedicine. The mHealth revolution introduces
                                                                                   beyond the young generation of clinicians.
communication-based care in a system that includes both wellness
                                                                                      For more information, attend the mHealth Networking and Web
and healthcare providers and puts patients at the center. mHealth is a
                                                                                   Conference to be held February 3–4, 2010 in Washington, DC. See
new field that already includes hundreds of vendors, thousands of
applications, and the use of simple, low-cost but intuitive technol-
ogy. Applications cover 12 areas: new communication with patients,                                                                        Address correspondence to:
access to Web resources, personal health record-on-the-phone and                                                                                C. Peter Waegemann
point-of-care documentation, communication-based disease man-                                                                                 mHealth Initiative Inc.
agement, on-the-phone educational programs, professional net-                                                                        398 Columbus Avenue, Suite 295
working as described above, administrative applications, financial                                                                                Boston, MA 02116
applications, emergency medical services=emergency department
services, public health, pharma=research, body area networks,                                                                                 E-mail:

                                     ª M A R Y A N N L I E B E R T , I N C . . VOL. 16   N O . 1 . J A N U A R Y=F E B R U A R Y 2 0 1 0   TELEMEDICINE and e-HEALTH 3

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