Sandra Bassendowski, RN, EdD,
Hazel Roberts, MD
and Thomas James
Petrucka, P., Bassendowski, S., Roberts, H. & James, T. (June 2013). mHealth: A Vital Link for Ubiquitous Health. Online Journal of Nursing Informatics (OJNI), vol. 17 (2), Available at http://ojni.org/issues/?p=2675
Mobile devices are increasingly present and prevalent in the health contexts both in developed and developing countries. This trend brings a number of possibilities of mobile health (m-health) to address critical aspects of health care and health system needs, by virtue of these devices’ ubiquity, simplicity, and cost-efficiency. This paper considers, as exemplars, three specific projects – Mobile Technology for Community Health from Ghana, Epi-Surveyor from various applications in developing contexts, and Enabling Nurses Access for Care Quality Knowledge through Technology from the Caribbean – in terms of their distinct contribution to vital aspects of health fulfilled through their unique m-Health offerings. These practical examples are used to demonstrate the potentials of m-Health to fulfill applications in community health, epidemiology, and acute care evidence-based practice. Specifically, they demonstrate m-Health’s potentials based in building awareness, capturing data on a near/real time basis, and remotely monitoring. The challenge put forward in this paper is that vital needs must translate into actual programs which are sustainable. It is critical that health providers are engaged and participate in realizing this preferred future.
Mobile technologies, m-health, information and communications technologies (ICT), developing contexts, remote monitoring
The use of mobile technologies (i.e., cellphones, tablets) for health and health care is increasingly ubiquitous connecting people and products across place and time. It has rapidly morphed from inceptional levels as wireless tele-health/tele-medicine to a widening array of technologies and devices to facilitate mobile health care delivery, thanks in part to networks such as General Packet Radio Service (GPRS) and 4th Generation Standards (4G), innovative wi-fi enablement, and smarter devices. Whether simple short text messaging (SMS) used in a range of applications including: sending information to patients, gathering information from health personnel and patients, getting answers to questions, connecting people to people, and performing transactions to complex and real time applications (i.e., diagnostic remote monitoring) where telemetry, constant monitoring, and interventions become possible, m-Health has the potential to leapfrog and emerge pre-eminent in the global healthcare toolkit within the next decade.
Despite the promise, we must remain cognizant that such approaches, although novel and glitzy, are emerging and need to be scrutinized in the context of programs/services and client/system outcomes. The potential to simultaneously impact quality of health care and health outcomes is indeed attractive. Within lies the opportunity for m-Health, generally, and remote monitoring, specifically, to intervene in the areas of prevention and promotion, at the individual, family, community, and global levels.
Erlbaum, Siegel and Doner (2003) suggest that the impacts of such devices are primarily anecdotal, especially in terms of the utility and influence on behavior and social changes for health. Mechael, Batavia, Kaonga, Searle, Kwan, Goldberger, et al. (2010) extensive review of m-Health literature concurred with these findings and suggested that a research focus on health outcomes is necessary for m-Health to become embedded in the promotion of healthy behaviors. Donner (2008) spoke about the confusion arising from the ‘blurring’ factor in which the mobile devices become integrated into professional and personal such that discernment between productive and routine uses is forfeited. These m-health tools tend to be simple and intuitive, which distinguishes them from the usual complex and skill-intensive devices in health care. In addition, the unique merging of technology and health has further challenged the knowledge building and translation; thereby further dissipating the literature and science. Cole-Lewis & Kershaw( 2010) considered research related to one tool such as text messaging suggesting that in developed contexts about 50% of studies indicated effectiveness of SMS as a tool for healthier behavior changes. Others such as WebTel (2011) looked at the cost implications to the health system of achieving such health behavior changes, estimating between one and seven percent cost reduction. Hence, there is a link to m-Health strategies and system-wide cost-efficiencies – many of which are only now being studied such as Tarassenko (2012) projections of 750£ savings to the National Health System in the United Kingdom.
Mobile health can be an equalizing attribute in developing countries. Through its ubiquity, it can potentially address the variable needs for access in rural, vulnerable, or otherwise marginalized populations. It can remove cultural and linguistic barriers through co-creation of content. Essentially it has the potential to improve health outcomes and, through integration, catalyze emerging health systems into m-health enabled environments.
Vital means necessary to life. There are innumerable projects and programs which have incorporated m-Health and remote monitoring to achieve the vital. This paper will consider three distinct projects to showcase mobile technologies in promoting healthy behaviors in developing contexts. Each project brings a unique application of the technology within the health care palette – contributing to the VITAL data sets which will potentially impact health in these emerging contexts. They were selected in terms of their diversity – Mobile Technology for Community Health in Ghana for building awareness of critical maternal client information; Epi- Surveyor globally for capturing real time data; and ENACQKT in the Caribbean for remotely monitoring of chronic health conditions (i.e., blood pressure). Each project will be briefly described and key findings highlighted as promising practices; with emphasis on the synergy in technology for health rather than process, operational or funding issues. The emphasis and intent shall be in creating the context and impetus to recognize the imperative of these mobile health strategies as the future path toward global health. Finally, a consideration of the preferred future of health care providers in this emerging and emergent environment is posited.
Through a Bill & Melinda Gates Foundation funding, the Mobile Technology for Community Health initiative arose through a partnership between Ghana Health Service, Grameen Foundation, and Columbia University’s Mailman School of Public Health. In July 2010, the project undertook a twofold approach to determine if mobile phones could impact the quantity and quality of pre-natal and neonatal care in rural Ghana (Grameen Foundation, 2011). The first application, Mobile Midwife Application, invited pregnant women to receive SMS or Voice Messages throughout the course of their pregnancy. Mobile Midwife provided information specific to pregnancy challenges such as nutritional information and healthier pregnancy practices, as well as providing alerts for care (e.g. prenatal care visits). The second application, Nurses’ Application, provided Community Health Workers with low-end mobile phones for health records and tracking purposes. The two applications articulated around the input into the systems and the output in the form of reminders to the clients. Additionally, the system enabled generation of patient lists, care provision, and generic reports.
From its inception, the combination of client-focused and provider-focused applications was seen as a strength. This not only connected the women virtually, but also created a linkage to the nearest health facility. These messages were generic (see Figure 1) and meaningful to a broad group – an unanticipated strength of the project. There was an assumption that women had mobile phone access, yet these devices were rarely personal but there tended to be a communal sharing of information and messages.
One of the key challenges in the MoTECH project included lack of a national health registration system, which complicated registration within the project (Grameen Foundation, 2011). Language was a challenge, not only in terms of dialects, but also in terms of messaging levels when working in developing contexts (Grameen Foundation, 2011). Another key challenge was lack of local infrastructure and capacities, which caused delays and compatibility issues from inception through delivery of the program offerings (Grameen Foundation, 2011).
Two key lessons learned included:
EpiSurveyor is an open-source surveying application that helps public health workers in many countries collect valuable health data. With more than 8000 registered users in over 170 countries globally (Datadyne, 2012). To date, EpiSurveyor has recorded more than 101,000 health record uploads (Datadyne 2010). According to the World Bank (2010), this program has been used in campaigns to curtail disease (e.g. see BBC (2008) on polio eradication projects in Kenya), whereby it identified early trends and indicators in the communities so that practitioners could intervene in a community plan. The program has been used to improve health system inter-sectoral coordination (e.g., see quality control initiatives – Aquaya.org) for such fundamentals as clean water and sanitation. Further, EpiSurveyor has contributed to educational efforts such as TulaSalud in Guatemala where it provided the platform for capacity-building in the form of monthly conference calls for health workers and community members on local medicines, nutrition, pregnancy concerns, and HIV/AIDS using mobile phones. One Health programs, such as the African Conservation Centre have benefited from the program’s strength in collecting and linking data sets for the betterment of animal and human health. In each program area, this tool has variably contributed by improving the skills of community health workers, increasing the availability and/or quality of care, and by capturing data in real or near real time.
Through mobile devices configured with this simple software, EpiSurveyor has addressed complexity, access, and cost effectiveness to bring the possibilities of quality data capture to the curbside. According to the developers, this program is a simple yet powerful software to ensure that evidence (data) will be captured to assess and inform health status and care indicators in developing contexts. Essentially the EpiSurveyor key lessons are that this program:
Enabling Nurses Access for Care Quality Knowledge through Technology (ENACQKT) was a ‘Mobiles for Development’ project funded by the International Development Research Centre which enhanced uptake and exposure to mobile health and health information via handheld devices for approximately 250 nurses in five Caribbean sites. ENACQKT established a user friendly information and communications technology (ICT) infrastructure with two objectives:
Rapid advances in low-cost, wireless personal area networks (e.g., Bluetooth) foreshadowed the emergence of remote health monitoring (RHM) as a crucial tool for affordable future healthcare delivery and management. The Economist (2010) headlined “Wireless health care: The next killer app?” which spoke to the future as a convergence of wireless technology, social networking, and medicine. During this project timeframe, continuous development and growing availability of sensor based devices such as portable blood pressure monitors and scales for personal gateways (i.e., iPad™ ; smartphones) emerged. The ENACQKT project added a clinical RHM application related to blood pressure (off the shelf models were used) monitoring in partnership with SaskTel and Alcatel Lucent. These sensor devices were selected in consultation with the participants and project team to focus in on conditions of chronicity [i.e., hypertension] as this is an area of increasing health pressures in the region. Implemented in mid-2010, this component was viewed as a value added application to the PDA acting as a relay and alerting device sending sensor readings to a remote server. The purpose was to demonstrate the value of layering a remote monitoring service into the existing ICT infrastructure using existing PDAs as an aggregation device. This component was a technical feasibility element rather than a clinical trial, so information was not linked to specific patients, but rather to patient locations (i.e., beds, communities, sites). Specifically, the units were used for free public clinics in malls and barbershops – essentially places where people meet and have some ‘uncommitted’ time. Although the sensor devices were limited to being data vaults in cases where there was no wireless capacity, the data was available and transmitted at the next available access.
The ENACQKT project built and co-created a user friendly information and communications technology (ICT) infrastructure inclusive of an array of wireless capable devices ranging from handhelds to remote monitoring devices to life-sized hi-fidelity simulation mannequins. A strength of this intervention lies in its promise as an appropriate, simple, and useful transition into ICTs and mobile technologies for the health sector in resource compromised sites. A second strength lies in the introduction of m-Health technologies in capacity building efforts through this project – highlighting the abilities and strengths of the project participants to use technologies to improve quality, care, and knowledge in their respective contexts. Two challenges were noted. First, a significant amount of work was needed to gain approvals before the project moved forward. Second, creation of the network was delayed or impeded due to various equipment, structural/infra-structural barriers, policy and procedural inconsistencies and/or gaps.
Ultimately the RMD component of the project showed significant promise – and this phase set a tone for inquiry and innovation. It allowed the participants to experience and accept (or reject) on their own terms an augmentation to their system. Nurses on units such as labour and delivery were highly interested and saw the RMDs as the future; other nurses such as medical unit staff felt they were awkward to implement in an institutional setting. One nursing participant aptly stated that
The remote blood pressure monitor would be a great way to get patient information from the clinics, hospitals, and community settings all in one place. I don’t know how, but I sure know why. We have so much high blood pressure here that we need some way to get people under control. And why not these tools – they are really easy and get the information we need to where we need it. I want to see other tools that (the researcher) talked about like the stethoscope and fetal heart monitor. It would revolutionize our health care here in St. Lucia.
(Personal Communication, Ernest Noeline, June 20, 2012)
Four key learnings respecting the remote monitoring sub-project showed:
According to the Webster Dictionary (2011), vital means “necessary to life”, as mentioned previously. The three examples are drawn from hundreds, if not thousands, of recent examples (and millions of dollars expended) on m-Health projects which are contributing to quality of life and health in developing contexts. This paper has suggested three vital contributions of m-health which these projects illustrated:
For health providers this means meeting the opportunity of m-Health at this crossroads, considering its potentials, and maximizing its utility, which Tassenko (2012) suggests includes its cost-effectiveness. According to Mars and Scott (2010), the major challenges facing ICT and e-health/m-Health implementation include resistance to change and a need to develop an information culture within health care (both which are related to organizational culture changes). As suggested in the MoTech project, m-Health is not the solution but the support; it neither replaces or displaces health providers, but enables and enhances their practices. It is a frequent concern that the technology is complicating or creates a barrier between patients and providers. However, in each of the three cases reviewed, this concern was either mitigated or refuted, partially due to the ubiquity and simplicity of these tools. Health providers at varying levels (i.e., community workers to professionals) demonstrated uptake and implementation of the technologies in the spirit of innovation and quality improvement. In the ENACQKT project, one nurse stated, “this project has changed the culture of our organization, our team, and our profession – thank you.” It is clear that the challenges outlined by Mars and Scott at the beginning of this discussion were clearly not only manageable, but indeed surmountable.
These global initiatives are indeed making a difference and will continue to incrementally and collectively contribute. The possibilities speak for themselves, however, governments, funders, users, and other stakeholders must continue to be involved and integrated in order to inject the vitality factor necessary to sustain and maximize these potentials. Ultimately, the health providers will be the vectors to this vital element’s entry and sustainability in developing contexts.
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Dr. Petrucka is a professor and nurse scientists with the College of Nursing, University of Saskatchewan (Regina Campus). Her program of research focuses on local and global health challenges for vulnerable populations.
Dr.Bassendowski is a professor and nurse educator with the College of Nursing, University of Saskatchewan (Regina Campus). She focuses on innovative teaching and learning strategies, technologies, and social media.
Dr. Roberts works with the Ministry of Health in St. Kitts and has recently embarked on a PhD at the University of Saskatchewan Community Health and Epidemiology.
Mr. James is the principal for Apogia Networks and was co-investigator on the ENACQKT project. He maintains a strong commitment to social networking and technology as a key element to development.