Restructuring healthcare delivery into an mHealth ecosystem

The Centers for Disease Control and National Institutes for Health report that more than 50 percent of the factors related to personal health can be traced to lifestyle choices, while only 10 percent are related to the medical care system. This finding illustrates a stark truth: The U.S. healthcare system in its current incarnation, a system of facility-based, episodic care, is insufficient to the task of improving population health. It's a growing crisis; an aging population, clinical staff shortages, cost inflation and uneven quality are heading us toward a potential healthcare tsunami.

What is needed is a delivery system with a greater array of provider-patient touch points, with better care coordination and clinical collaboration, with diagnostic tools for self care, with aligned incentives and with the capability of achieving behavioral change across the spectrum of healthcare stakeholders. What is needed is a patient-centric healthcare ecosystem.

In a general context, a health ecosystem describes the interplay of many factors, including the environment, personal attributes and relationships, cultural influences, technology and health resources that affect individual health status. The idea of a healthcare ecosystem envisions an environment of comprehensive, high quality, convenient, affordable, personalized and accessible care. In this ecosystem patients and consumers are empowered through education, knowledge and tools to be their own health managers. The healthcare ecosystem places a strong emphasis on health promotion, wellness and prevention, as well as self-management.

From health ecosystem to mHealth ecosystem
Taken one step further, the mHealth ecosystem is about extending access and remote connectivity within the industry. It's about engagement among providers, with patients and consumers, with payers and employers, public health and social services, with every healthcare industry stakeholder. In both clinical and business applications, mHealth is aimed at the creation of a connected healthcare ecosystem through the integration of mobile communication, transactions and knowledge.

This community includes payers, providers, consumers, vendors and telecommunications. It harnesses the collective power of enabling technology, efficient resource allocation, clinical decision support and persistent patient care. The connected healthcare ecosystem plays well with emerging industry payment and delivery models like the accountable care organization, the patient centered medical home, meaningful use, aging-in-place and early intervention. And at its heart, the mHealth ecosystem addresses healthcare's most intractable problems --unsustainable cost inflation and uneven clinical quality.

To perform efficiently, the mHealth ecosystem must be convenient, connected, coherent and cost-effective. Its organizing principle is alignment of the inputs to healthcare -- the verticals, the venues, the spectrum of caregivers, the technologies, the workflows -- within an integrated, interoperable system architecture that is efficient and accessible. The mHealth ecosystem is characterized by innovation in care delivery, robust care teams and heightened clinical collaboration, an epidemiological health perspective (including population health, prevention and wellness), utilitarian technology solutions and consumerism. Most important, it is about recasting the terms of healthcare delivery by placing the patient in the solid center. "Nothing about me, without me" captures the conceptual framework of a healthcare ecosystem in which the patient is the central figure. Information is now portable, personalized and participatory, making a patient-centric mHealth ecosystem unbound by age, location or economic strata.

If I build it will they come?
For the mHealth ecosystem to reach its fullest expression, the main issue that must be addressed is defining, attracting and retaining the customer.

The mHealth customer is unlike the traditional buyer of healthcare services, because where traditional healthcare is sold on a B2B or B2C basis, mHealth is largely a retail market. Although clinicians (mainly doctors and nurses) account for a proportion of mHealth market growth, the primary driver to date has been the consumer. They're not just buying smartphones and tablets in stores and online, they're buying apps, medical devices and services. But in healthcare, direct to consumer has had a mixed record of success.

For several years now, an ongoing problem obstructing the patient-centric model of healthcare has been getting the healthcare consumer -- not only the patient with issues, but the enlightened public as well -- actively engaged in digital health. After all, patient-centric healthcare without patient involvement is just an illusion. To date the patient portal hasn't proven to be the form horse of consumer engagement, and neither has the PHR. Why? Because in the main consumers choose to avoid the tedium of entering and maintaining their own health data.

But that pattern of behavior is not repeating itself in the mobile world. Consumers are mimicking the kind of digital convergence, the intersection of personal and professional applications via mobile technology, which is a growing feature of clinical workflow. Once someone has a wireless device, that person is more likely to use the Internet to gather information, share information and create new content.

These patterns are beginning to emerge in Americans' pursuit of health information on mobile devices. Wireless connections and devices are associated with deeper engagement in health-related social media. It's not just young adults either who are driving the consumer movement toward mobile health. The "wireless pack" of healthcare consumers extends from 19 to 50 years old. These consumers are using their smartphones to manage weight, stop smoking, check vitals, get health tips -- in sum, to keep personal health records.

Making the leap to the mHealth ecosystem
It's been widely reported that mobile health is a leapfrog technology, providing a platform for the care of populations that possess established mobile networks but a weak healthcare infrastructure. Conceptually, a simple cellphone removes access and distance as barriers to both routine and chronic care. That opportunity to improve outcomes for the underserved -- poor, rural and minority populations -- is staring at us right here at home.

At a baseline level, mHealth will become both an adjunct for and a substitute to the office visit by providing culturally appropriate health information, medication reminders, lifestyle advice and bilateral doctor-patient communication. In more advanced applications, mHealth solutions will serve as the conduit for patient treatments via remote patient management tools, self-care and telemedicine.

One of the most intriguing opportunities to fast-track an mHealth ecosystem exists in developing countries, where the infrastructure to support a fixed wired healthcare industry simply doesn't exist. Of the estimated 4 billion mobile devices in use around the world, 64 percent are in the hands of people living in emerging market economies. Although the level of mobile technologies has not yet reached the sophistication of advanced nations, in developing economies mHealth offers a far more cost-effective and achievable alternative to establish an integrated, collaborative healthcare finance and delivery ecosystem. Though the analogy of mHealth's impact in the developed world doesn't directly translate to the domestic healthcare landscape, we can "reverse-engineer" mobile healthcare successes elsewhere in the world to boost outcomes for our most vulnerable populations, and weave those proven technology solutions into our domestic mHealth ecosystem.

What will it take?
However, we're not there yet. It's going to take a wholesale restructuring of healthcare delivery to achieve an mHealth ecosystem. That includes culture change on the part of payers, providers and patients, a new definition of clinical "value" based on mass personalization of the care experience, partnerships that deliver collaborative, coordinated care and team-based care delivered through new care systems including PCMH, the ACO and health information exchange.

It's going to take a realignment of payment incentives tied to the shift from volume to value as the primary metric of reimbursement, with attendant tools to measure and manage. It's going to take interoperability and connectivity of information systems and information channels. And finally, it all must translate into improved operating efficiencies and bottom line revenue in order to succeed.

Learn more about these issues and more at the 2012 mHealth Summit, scheduled to take place Dec. 3-5 at the Gaylord National Resort and Convention Center just outside of Washington, D.C.

Rick Krohn, MA, MAS, is president of HealthSense and an expert in healthcare corporate strategy and strategic marketing, business development, corporate communications, technology development and commercialization. He is co-editor, with David Metcalf, PhD, of the 2012 HIMSS publication titled mHealth: From Smartphones to Smart Systems.