The ROI behind mHealth

News 13 March 2012

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For well over a decade, health systems around the world have been conducting large-scale trials of mHealth solutions as they seek new ways to empower patients, improve quality of care, deliver efficiencies and drive up productivity. The results have been staggering.

For example, the use of telehealth has transformed the lives of patients with chronic, or long term, conditions by enabling them to monitor their own vital signs at home and send them quickly and accurately to a health professional.

Results from the UK’s Whole System Demonstrator project1, the world’ s largest randomised and controlled trial of telehealth involving 6,000 patients, demonstrated that, if used correctly, telehealth can lead to a 45 per cent reduction in mortality and a 20 per cent reduction in emergency admissions to hospital.

Similarly, the Veterans Health Administration’s Care Co-ordination/Home Telehealth (CCHT) programme in the US has shown huge benefits. CCHT was developed to help meet the needs of rising numbers of elderly veterans with chronic care needs. It was introduced in 2003 and involves trained nurses providing telehealth services to veterans with long term conditions such as diabetes, hypertension, congestive heart failure and chronic obstructive pulmonary disease.

By 2008, over 30,000 veterans were enrolled in CCHT and the data gathered over the years show that it reduced hospital admissions by 19.7 per cent and bed day occupancy by 25.3 per cent – and all at a cost of around one-eighth of the equivalent traditional services2.

Similarly, mobile working – providing community-based healthcare professionals with mobile access to electronic patient records and the ability to write their notes on the move – has been shown to deliver increased productivity and allow clinicians to spend more time with patients.

In the UK, clinicians using mobile systems reported fewer referrals to other services and fewer admissions to hospitals as they were able to solve problems on the spot3.

Not quite mainstream

Despite the impressive results, telehealth or mHealth solutions have yet to go mainstream in the US, the UK or in most other developed countries.

“If it is such a good idea, why isn’t everyone using it?” asks Stephen Johnson, head of long term conditions for the Department of Health in England. “The big barriers are getting the evidence that it works and finding the money to install the technology.”

He is not alone in this view. The World Health Organization made the same point in a report in 20104. The evidence was there, it suggested, but not in a form that was acceptable to clinicians. As it states in the report: “Making the case for investment in telehealth applications requires better marshalling of existing evidence, not only to show that telehealth works, but also to show where – in what organisational context – it will work.”

Nick Goodwin, a fellow at UK think tank The King’s Fund, reached the same conclusion after convening an international conference in 2011. Too often, he says, the research and evaluation of mHealth solutions has been too academic.

“Research and evaluation needs to be much more closely aligned with innovators and decision-makers to enable them to utilise the best available evidence in ‘real-time’,” he says. “Traditional research and evaluation studies are not conducted to facilitate such rapid knowledge-transfer and those at the ‘coal-face’ of delivery rarely listen to it when it comes. New methodologies and approaches are needed and this will only come to fruition through better co-operation between scientists, professionals, product developers, and policy-makers.”

This is starting to happen, driven partly by the growing realisation that all countries face a rise in the number of people with long term conditions – and that the added burden will make health systems in their current form unsustainable.

Johnson puts it bluntly: “The care of people with long term conditions accounts for around 70 per cent of the total health and social care budget – that is, £70bn. It is indefensible to suggest that we cannot find a way of using that money better to deliver improved outcomes.”

He argues that the barriers can be overcome. The UK Department of Health launched its “3millionlives” campaign5 with precisely this aim in mind: to provide telehealth services to three million people with long term conditions over the next five years. In January 2012, the Department of Health signed an agreement with industry leaders in which they agreed to find new business models that will overcome the barriers of heavy upfront capital investment.

In 2011, the Department of Veteran Affairs in the US awarded six contracts worth $1.38bn to extend the use of telehealth. Meanwhile, the Australian government announced it was to pour $620m into making the telehealth concept a reality. Both initiatives will take adoption of mHealth solutions to a new level.

“Telehealth has transformed my life”

This is not just about numbers, though. It is about people’s lives, as Haris Patel attested at the UK launch of the 3millonlives campaign in January 2012.

Patel is 53, has a heart condition and suffers from Parkinson’s Disease as well as hypertension. He has had several strokes and is a wheelchair user. He used to spend an average of eight-to-ten months a year in hospital.

Four years ago, he received a telehealth package tailored to his particular needs. He had monitors installed so he could take his own blood pressure and other readings and send them electronically to be reviewed by a nurse.

He and his family learned more about his condition using the system and he received regular visits from the district nurse when his readings went outside the expected parameters. No more days waiting for the GP to take his blood pressure, no more pointless routine trips to outpatient clinics.

In the four years since he began using telehealth, he has spent three weeks in hospital. As he says: “Telehealth has transformed my life.”

The evidence emerging from the UK’s Whole System Demonstrator project is that patients like Haris Patel respond positively to mHealth solutions. Soon-to-be published data will show patient satisfaction rates over 95 per cent – patients like being in control of their own healthcare and they like receiving their care at home rather than travelling to hospitals and clinics.

Small scale is important too

This thirst for freedom that technology can deliver to patients is one of the drivers behind investments made by companies in new mHealth applications.

For example, there has been an explosion in health apps. This was amply demonstrated by an initiative by the UK’s Department of Health, which last year asked the public to name their favourite health apps. Over 500 were nominated – and over 12,600 people commented6. There were apps for tracking blood glucose, for tracking mood, for helping people with food allergies and for patients to access their own healthcare records.

Health secretary Andrew Lansely is now looking to harness some of these – and make them available for patients via the health service. At an event in February 2012, he said: "So many people use apps every day to keep up with their friends, with the news, find out when the next bus will turn up or which train to catch. I want to make using apps to track blood pressure, to find the nearest source of support when you need it and to get practical help in staying healthy the norm.”

Meanwhile the US Food and Drug Administration has approved the first iPhone glucose meter, Sanofi’s iBGStar. Already available in five European countries, it enables patients with diabetes to analyse their glucose patterns over time and share it with clinicians.

There are doubts though about the ROI on health apps. In January 2011, research analyst firm Cutting Edge Information (CEI) published a report suggesting pharma companies look to clinical trials and other pre-launch activities as the ripest opportunities for leveraging mobile health apps.

“With usage retention rates likely to continue hovering in the single digits, the industry may soon conclude the market is saturated with mobile health apps,” CEI wrote in a press release. “Despite the low cost of development, a reasonable ROI is much more difficult than first envisioned.”

Elsewhere, pharma is investing in novel technologies to support medication adherence – in other words, new ways of encouraging patients to take their medication regularly. Novartis recently invested $24m in “chip-in-a-pill” technology developed by Proteus Biomedical. This involves a microchip embedded in existing drugs for transplant patients. Once ingested, the chip can transmit information about whether a patient has taken a drug as well as feedback about how it is affecting them7.

It is already in use, although not widely, and as with other technologies there will be the inevitable questions about the evidence base. But as Dr Goodwin says: “The evidence-base is essential to support the effective transition to a new way of working, but its limitations can too often be used as an excuse to do nothing. The time for system redesign is now.”