Health IT
Session 7
mHealth and Digital Business Models
Abhay Nath Mishra
Professor and Kingland Systems Faculty Fellow
Iowa State University
Agenda
• What is mHealth?
• Why mHealth in India?
• What are the barriers to the adoption of
mHealth technologies?
• How is the quality of mHealth evaluated?
• How is mHealth reimbursed?
• How much value does mHealth deliver?
• HCAH case discussion
mHealth entails the use of mobile and wireless devices
to improve health outcomes, healthcare services, and
health research. - The NIH Consensus Group
mHealth is an area of electronic health (eHealth) and it
is the provision of health services and information via
mobile technologies such as mobile phones and
personal digital assistants (PDAs) and other wireless
devices. – WHO
Similar wording by US HHS
Type of Care Delivered
Preventive Reactive Proactive –
anticipatory
Personalized
Locus of Care Delivery
(individualized)
Organisational
(hospital/institution/
clinic)
Societal (population
level)
Types and Locus of Care
• Preventive: maintaining good health and preventing diseases by
avoiding or reducing the occurrence of health problems and illnesses
before they become more critical (e.g., routine check-ups, vaccination,
healthcare screening, healthy lifestyle promotion)
• Reactive: addressing health issues and medical conditions after they
have occurred. This type of care is delivered when specific symptoms,
diseases, or emergencies are present (e.g., treating injuries, managing
chronic conditions, surgery, inpatient monitoring, and treatment)
• Proactive/Anticipatory: focus on early detection and interventions
to prevent or mitigate the progression of health problems; deliver care
early before the problem becomes difficult to treat; involves clinical teams
and social care providers to ensure that the individual's preferences and
their families are considered (e.g., remote care monitoring, person-
centered care plans)
• Locus of care: where the care is delivered or who is delivering the
care (individual, organisation, society/family)
Sarker, Bardhan, Mishra, Oborn, Tan, Tremblay 2024
Potential of mHealth
• Doctor consultation
– Removal of geographical barriers
– Enhancement of health equity
• Remote patient monitoring and consultation
• Chronic disease management
• Self monitoring
• Preventive care and wellness
• Public health surveillance and compliance
• Health information dissemination
• Granular data and analytics
• Education, awareness, and training
Potential of mHealth in India: Tech Upside
• Number of mobile phone users in India: ~ 1.2
billion
• Number of mobile phones in India: ~1.5 billion
• Average mobile data consumption in India per
user per month: ~19.5 GB
• Home health care market by 2027: $21.3 billion
Source: Statista and others
Number of smartphone users in India in 2010 to 2023, with
estimates until 2040 (in millions)
1,800
1,600 1,522.83 1,549.01
1,536.51
1,507.86
1,491.49
1,473.52
1,453.73
1,431.91
1,407.77
1,381.04
1,400 1,351.32
1,318.2
1,281.18
1,239.68
1,193.03
Smartphone users in millions
1,200 1,140.42
1,080.95
1,013.57
1,000 938.27
853.42
800 757.2
642.34
600
485.14
399.4
400 307.75
253.09
191.67
200 130.11
91.26
34.1859.08
0
https://www.statista.com/statistics/467163/forecast-of-
smartphone-users-in-india/
Potential of mHealth in India: Market and
Infrastructure Realities
• Widespread systems barriers (accessibility,
availability, affordability)
– Health professional shortages
– Shortage of hospital and other care facilities
– Reliance on untrained and unprofessional workers
– Cost of services, lack of transportation, inadequate
information and medical literacy
• Payment model – out of pocket – has implications
• Huge potential for mHealth!
Source: Statista
Some Prominent mApps
1mg: Online pharmacy
HealthyYou EHR: Free electronic health record
Lybrate: Emergency support system with tools for finding ambulances, booking appointments, and managing
medical records
mSwasthya – CDAC: Vaccine alerts, medication monitoring, hospital search, OPD scheduling, Indian health
statistics
mTikka: Cloud-based infant registration and vaccination recordkeeping
TB Detect: TB screening algorithm
Tejasco Track Your Vitals: App for tracking labs, pharmaceuticals, and other health information
Veegilo: Report and track disease outbreaks
Some Prominent mApps for Doctor Consultations
• Practo, mfine, DocAps, 1mg, Netmeds, Lybrate,
MediBuddy, and Medlife
• Practo, mfine, and Lybrate – consultation through
chat, audio, and video calling
• DocAps, and Netmeds – chat and audio calling
• 1mg – free chat consultation
• MediBuddy, and Medlife – audio call consultation
only
• Offline consultation: Practo, mfine, 1mg, Lybrate
Source: Statista
Adoption Issue for mHealth:
Requiring behavioral change
• Getting people in the
habit of recording
something, with the
hope they’ll develop
another habit as a
result
– Glucose logging
– Diet logging
– Water logging
– Logging anything…
Image source:
Glucose Buddy page on the Apple App Store
Solution:
Integrating with existing behaviors
• Using technology to
enhance existing
behaviors, rather than
creating new ones
– Putting a cellular
antenna in a glucometer,
so that data is
automatically shared
with providers and apps
– Putting a WiFi chip in a
scale, so that weight is
automatically recorded
Image sources:
http://blog.withings.com/wp-content/uploads/2012/11/wbs01-seule-Limited-Edition.jpg
http://www.bgstar.com/cp/medias/app/BGSTAR_COM_EN_iBGStar_app_zoom_synchron.jpg
Problem:
Having no immediate benefit
• Suggesting people
perform some sort of
activity that has no
immediate benefit,
although it may have
long-term benefits
– Tracking long-term
impact wellness
activities
– Prompting people to
take preventive
medications
Image source:
Waterlogged App for iOS
Solution:
Focusing on the short and long term
• Provide people with
both immediate and
long-term rewards for
their activities, so that
they remain engaged
– Provide social
encouragement
– Provide financial
incentives for good
behavior in real-time
Image source:
http://technabob.com/blog/wp-content/uploads/2012/01/gympact_iphone_app.jpg
Problem:
Requiring adherence
• Requiring people to
continue to do
something in order to
deliver a benefit
– Wearing something
– Logging something
– Taking something
Image source:
http://ecx.images-amazon.com/images/I/51rrR9KFu1L._SL1024_.jpg
Solution:
Anticipating poor adherence
• People often are non-
adherent because they
either do not feel they
benefit from adhering, or
feel they are harmed
from adhering
• Build systems that
anticipate low adherence,
rather than ones that
require good adherence
– Send reminders if
adherence is poor
Image sources:
http://ecx.images-amazon.com/images/I/51rrR9KFu1L._SL1024_.jpg
http://www.jawboneuppromocode.com/wp-content/uploads/2013/10/jawbone-up-4.jpg
https://static6.fitbit.com/simple.b-dis-png.hb450d61faad3f6ac2a69902bbd0f3a79.pack?items=%2Fcontent%2Fassets%2Fproduct%2Fultra%2Fimages%2Fone-announcement-the-one.png
mHealth solutions have varying levels of risk
weight heart rate diagnostic
measurement measurement interpretation
Minimal High
sleep activity treatment glucose
logging
tracking tracking recommendations measurement
The U.S. FDA has taken a risk-based
approach to regulation
Regulated apps either:
-Are intended to be used as an accessory to a
regulated medical device
-Transform a mobile platform into a regulated
medical device
Based on the Mobile Medical Applications Guidance for Industry and Food and
Drug Administration Staff document, released by the FDA on September 25, 2013
The FDA exercises discretion in regulating apps
that pose minimal risk
• Help patients/users self-manage their disease or condition
without providing specific treatment suggestions
• Provide patients with simple tools to organize and track their
health information
• Provide easy access to information related to health conditions
or treatments
• Help patients document, show or communicate potential
medical conditions to health care providers
• Automate simple tasks for health care providers
• Enable patients or providers to interact with Personal Health
Records (PHR) or Electronic Health Record (EHR) systems.
Based on the Mobile Medical Applications Guidance for Industry and Food and Drug
Administration Staff document, released by the FDA on September 25, 2013
Available reviews are inadequate
Image sources:
Apple App Store HealthTap
Apple App Store and HealthTap for iOS screenshot
What are some of the issues with the reviews of
mHealth apps on app stores?
1. No detail
2. No clinical review
3. No security review
4. No effectiveness review
5. Authority of reviewers often unclear
Do we need external review?
• Issues with external review:
– Frequent updates to apps
– Reviews are slow to appear
– Reviewers have missed issues
– Not scalable
• Proposed alternative
– Self-review by patients and
physicians
– Awareness training
Arguments for external review
• Issues with self-review
– Can’t assess security
– Can’t assess efficacy
– Often can’t assess privacy
• External review options
– Automated review,
correlating app use with
sensor data
– Manual review by experts
Explore behavioral economics inspired
app design approach
• Men are reluctant to seek care, even when in pain
• Use behavioral and digital nudges for preventative care?
• Nudge – freedom preserving, no banning, no overt
economic incentive
• Cognitive nudges < Affective nudges < Behavioral Nudges
– Digital default option
– Digital reminder option
– Color coding
– Providing multiple points of view
– Reminder of harm
– Obtain precommitment
Additional challenges
• Lack of clinician involvement
• Poor attention to usability
• Lack of adherence to regulations
• Lack of privacy
• Surveillance capitalism
• Widely varying regulatory landscape
Why financial coverage of apps matters
Better financial
coverage
More utilization
More app
by patients &
development
providers
Who pays for apps today?
• It depends on the app and how it is used
• Payments are made by:
– Patients
– Healthcare providers
– Employers
– Insurers
• The nature of the item garnering payment also varies
– Some payments are for the apps themselves
– Some payments are for services that are delivered with the assistance
of apps
The Uber example
• Uber has an app
• People pay Uber money
• Payments are for app-
facilitated
transportation services
• Payments are not for
the app itself
Patient-centered value can be ascribed
to apps using 5 numbers
Average effect size of Engagement Duration of the
Value of a QALY, QALYs lost due
in monetary terms to the condition the app’s health impact rate of app users app’s impact
Source: Powell AC & Torous JB. 2020. At What Price?: A Framework for Measuring the Value Delivered to Patients by Digital Health Apps. Working paper.
Patient-centered value can be ascribed
to apps using 5 numbers
Average effect size of Engagement Duration of the
Value of a QALY, QALYs lost due
in monetary terms to the condition the app’s health impact rate of app users app’s impact
• These five levers are different for each nation, health condition, mechanism of action, and
app implementation
• Some countries are more willing to spend money on a Quality-Adjusted Life Year (QALY)
than others
– Value of a QALY is $50k-$500k in the U.S., with $175k used by the Institute for Clinical and
Economic Review as the line at which a tool is no longer “low value”
– Value of a QALY is £20k-£30k per QALY ($25k-$40k) in the UK
• Some conditions cause greater loss of health than others
• Some ways of treating conditions are more effective than others
• Some apps maintain better user engagement than others
Source: Powell AC & Torous JB. 2020. At What Price?: A Framework for Measuring the Value Delivered to Patients by Digital Health Apps. Working paper.
Example: U.S. depression app
Average effect size of Engagement Duration of the
Value of a QALY, QALYs lost due
in monetary terms to the condition the app’s health impact rate of app users app’s impact
• Value of a QALY: $175,000
• Depression’s impact on QALYs: 0.159 (from the EQ-5D)
• Average effect size of the app’s health impact: 50% reduction in symptoms
• Engagement rate of users: 4%
• Duration of app’s impact: 25% of a year
• Value: 175,000 per QALY * 0.159 QALYs lost per year of depression * 50% reduction in
symptoms * 4% receiving effective dose * 0.25 years of improvement = $139
• Implied monthly subscription cost: $10-15/month
Source: Powell AC & Torous JB. 2020. At What Price?: A Framework for Measuring the Value Delivered to Patients by Digital Health Apps. Working paper.
Example: UK anxiety app
Average effect size of Engagement Duration of the
Value of a QALY, QALYs lost due
in monetary terms to the condition the app’s health impact rate of app users app’s impact
• Value of a QALY: £20,000 = $25,000
• Anxiety’s impact on QALYs: 0.070 (from the EQ-5D)
• Average effect size of the app’s health impact: 50% reduction in symptoms
• Engagement rate of users: 17%
• Duration of app’s impact: 25% of a year
• Value: 25,000 per QALY * 0.070 QALYs lost per year of depression * 50% reduction in
symptoms * 17% receiving effective dose * 0.25 years of improvement = $37
• Implied monthly subscription cost: $3/month
Source: Powell AC & Torous JB. 2020. At What Price?: A Framework for Measuring the Value Delivered to Patients by Digital Health Apps. Working paper.
HCAH’s Approach to Care
• Holistic – “phygital”
• Use patients’ homes as a distributed hospital
• Intensive care, post-op, nursing, physio, day-surgery, stroke
rehabilitation, oncology, home dialysis, diagnostics with lab,
pharmacy, medical equipment
• Step-down beds, attendant services, elderly care
• Patient-centric approach to care
• Enormous focus on health worker recruitment
• Continuous improvement through training and
accreditation
• Partnership with insurance companies, hospitals, and
employers
HCAH: Delivering Innovative Home
Health Care in India
• Challenges and Opportunities
– Sustaining growth and leading change
– Fierce competition in a growing market (2nd largest aging
population in the world)
– Vast underserved population (300 million middle class)
– Scarce availability of skilled workers
– Development of processes for seamless delivery of remote
care
– Negotiation of service ownership with patients and
families
– Mitigating risk to home health workers; social issues
related to caste, religion, and other aspects; trust
Conclusions
• mHealth can and is playing a key role in improving
healthcare
• Quality is variable; evaluate app quality
• mHealth app design is important; long-term app health
use/adherence is low
• Involvement of clinicians and consistency with
regulations is key for growth
• mHealth app reimbursement is a critical issue to resolve
for individual users, payers, and providers
• Significant mHealth opportunities in India but also
considerable challenges
For Next Session
• Session 8:
– HBS/ACRC Case HKU765: ITC E-Choupal: Corporate
Social Responsibility in Rural India
– Elrod and Fortenberry article
