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Welcome to Day Six of Echoing Green’s Mobile Technology in Social Innovation online series. Today’s focus is on Health.

Panelists: Andre Blackman of Pulse+Signal, Isaac Holeman of MedicMobile, and Josh Nesbit of MedicMobile

How does your organization use mobile technology?

Josh Nesbit: Medic Mobile uses mobile technology to support health workers and patients in challenging settings around the world. From stock monitoring in rural Ethiopia, to coordinating tuberculosis care in Malawi, to emergency response after the earthquake in Haiti, we use mobile when it's the best—and sometimes only—way to send and receive information in the last mile.

Isaac Holeman: Medic Mobile helps health workers use mobile technology to connect and coordinate their services, with a focus low cost phones and areas with poor connectivity. We have some exceptional engineering talent on the team, but our approach on the ground is to help clients do as much as possible with existing free and open source tools. Sometimes these are tools Medic Mobile created (like SIM apps), but more often they were created by other organizations (like FrontlineSMS) or involve modules that Medic Mobile created to extend another organization's software (PatientView is a module that extends FrontlineSMS). This sets our work apart from organizations that expect a substantial investment in software development and customization for every project.

Andre Blackman: Being primarily in the nonprofit and health communications industries, I’ve seen many organizations using mobile technology for fundraising, health communications outreach (KNOWIT campaign from AIDS.gov, Text4Baby) and generally staying in touch with supporters/target audiences. From basic SMS opt-in programs like what the CDC has done for a number of initiatives to creating actual devices and smartphone applications - the mobile revolution is here and from all the reports/research being done, it’s not likely to go away anytime soon. In fact, it’s the future.

What is the greatest hurdle facing mobile health?

Andre: There are a number of concerns that I can think of regarding the current situation with mobile but I think the one that stays on my mind the most is defining the space. We hear a lot of talk regarding mobile apps and building health apps for the iPhone or Android devices however understanding hype vs. what works is important. Mobile health is starting to encompass a lot of material and I think making sure that various groups in health can understand what parts fit with their programs is going to be a hurdle—especially with the onslaught of various events/conferences that have been developed.

Isaac: Our field is getting past small pilots projects, initiatives are starting to scale up and need to be maintained long term. In less developed countries most of the funding in this space currently goes to organizations that work in only one part of a given country and on a 2-5 year grant cycle. We now need to fund and build capacity for national information systems that integrate multiple health care providers (i.e. ministry, nonprofits and mission organizations), and find a way to support these projects long term.

Josh: Mobile technology is repeatedly presented as a solution. It's not—it's a tool that transforms into a solution when people use it within a health system. The more that technology is regarded as a stand-alone solution, the less likely it is to deliver impact.

How can/do mobile health interventions overcome issues of language and literacy? Do they?

Josh: First, "proximate literacy"—the idea that if you may not be able to read and write, but your wife, son, or fellow community health worker can—is very real. Second, we've seen SMS programs increase literacy; a friend in Nicaragua recently commented that she'd rather design systems for the users' future as opposed to making assumptions about the permanence of past skills (or lack of skills). Of course, integrated voice response, voice-to-text, text-to-voice, and MMS-based systems can help in low-literacy populations. Finally, language isn't really an issue if programs and products are designed alongside users.

Isaac: FrontlineSMS now supports Bengali for our work in Bangladesh, which was an interesting technical challenge because Bengali uses non-roman characters. More broadly, there are many forms of literacy and numeracy, and mobile phone literacy is growing much faster in Africa than other forms of literacy. Villagers are motivated to teach themselves to use phones, and they have resources in their communities from whom they can learn. Dealing with literacy is often more about accommodating the local context than having technology or health interventions that teach health workers new things.

Andre: A few months ago there was a Twitter chat hosted by HealthFinder.gov and Cynthia Bauer, CDC’s Senior Health Literacy Advisor - I wrote a recap of the event where I highlight this very question. I received an answer from Linda Harris of the Office of Disease Prevention and Health Promotion—her answer (more fully explained in the post) basically pointed to the fact that there are various communities across the country that need to have tailored communications created to optimize the health information. Also, creating easy to understand mobile campaigns that easily integrate into lives will be extremely helpful. Finally, here is a great research article on the concept of low literate communities and patient education on mobiles from MobileActive.

“...the digital divide is still very much a reality and more research is needed to assess the reach and impact of mobile health. We are also beginning to work across agencies to explore and define the concept of ‘digital literacy’” - Linda Harris

How is mobile health contributing to better health outcomes? How can it do so more effectively?

Issac: Medic Mobile works in areas where health systems are really struggling, so we focus on health worker to health worker communication that improves service delivery. Health workers need to mobilize other health workers when they refer a patient or a patient needs to be found after a missed appointment, when stock of an essential medicine runs out, and leaders need basic operational data so that they understand in a timelier manner where their attention is needed. We know a few approaches that work well at a small to medium large scale (though we lack important research around which interventions have a bigger comparative impact than others). Now we need to figure out the institutional arrangements that will enable these pilot cases to scale up and create nationally integrated information systems.

Andre: Mobile technologies are helping to provide flexibility to health workers around the world where there may have only been paper/pencil type recording materials. Now with mobile devices health workers are able to collect data from home visits with patients and send the results back to central repositories of patient records. This provides incredible increases in productivity and cuts down on turnaround time for hospitals/clinics to provide valuable service to their communities. In a presentation that I created about 2 years ago, I highlighted this video where Nokia’s mobile technology program was helping health workers in Brazil. 

In the States, physicians are starting to make use of tablets and other mobile devices to have up-to-date, constant access to patient’s electronic medical records as well as other important information to help treatment. From the patient perspective, making use of mobile health devices such as the Fitbit, gives individuals the power and opportunities to improve their own health. Jane Sarasohn-Kahn, noted health economist and mHealth advocate wrote about this topic earlier this year. By making sure that mobile technologies are properly developed for the needs of various health professionals (physicians, public health workers), better outcomes will continue to surface in the health world.

Josh: We've seen a lot of retrospective analyses of the impact of mobile health programs, e.g. our pilot project in rural Malawi, where TB patient capacity doubled and there were intense time and cost savings. We're now seeing a shift to prospective, two- and three-arm trials that will help build a knowledge base about what works and what doesn't. Some of it might surprise us. There is no need to rebuild open-source technologies, but I definitely support more experimentation, more research, and faster failures that lead to bigger successes. We'll need funding to make that happen.

How can low-resource setting models learn from high-resource, and vice versa?

Josh: Truth is, community health centers and CHWs providing care for the underserved in the U.S. face challenges very similar to those in low-resource settings internationally. That said, the regulatory and funding environments are different. We can move from idea to implementation in international settings, which I think means we'll see quicker innovation abroad that will make its way back to the U.S. when we (Americans) realize that disruptive methods and tools are absolutely necessary.

Issac: In North America the little innovator is too frequently priced and regulated out of the market. In low resource settings we're proving that free and open source software works, and that it's most cost effective to focus on the first 80% of what you need because the last 20% tends to be so complicated and locally specific that it drains all your resources and hurts the project's ability to replicate. We're proving that small productive groups can do incredible work; you often do not get better results by paying an enormous corporation millions of dollars to build a software application that should be simple. The funding constraints press us to be creative and aggressively contain costs in a way that the multi-billion dollar North American health IT market doesn't need to.

While I see more products and organizational models transferring from low-resourced areas to high-resourced, there is an important role for individual talent and technical experience moving in the opposite direction. Graduates of top schools in the U.S. are turning down huge salaries and more experienced professionals are quitting their jobs for projects in Nairobi or Mumbai because it is so exciting to leave the cubicle and do something important, to have space for real innovation and share your experience with brilliant people who haven't yet had access to top tier schools and mentored work environments.

Andre: Like I mentioned above where global mHealth initiatives are making big impact in low-resources communities, the vice-versa question can be answered a few ways. The first thing that pops into my head is that many of the initiatives I see happening overseas can somehow be translated into the needs going on in certain areas in the States, primarily in rural areas. Rural areas in places like North Carolina often can mirror situations faced in the global health setting--however infrastructure around mobile connectivity is very different here.

The cost inflation around text messaging and data packages is enormous compared to what people can afford in low-income, rural communities. This can be a great place to innovate when examining lessons that the “high-resource” United States can learn from low-resource settings. As far as high resource settings such as hospitals or even commercial use of mobile technology, one of the things that can be learned is simplicity is key. Once you understand the communities you are building mobile initiatives for, the rest can be maintained well when things are kept simple and happily integrate into lifestyles.

How will mobile phone technology be different in 5 years?

Andre: Mobile phones are turning into hubs for daily life—around the world, people are able to make purchases, communicate beyond voice, get work done and stay on top of valuable information all through the device in their hand. I think this will only continue to be the case in the next 5 years as the definitions of smartphones change and their availability is increased to populations.

Josh: Five years is a long time! Mobile payment systems will be ubiquitous, phones will power themselves, low-cost mobile diagnostic add-ons will be normal tools for remote health workers, you'll have to recycle your old phone to get a new one, and penetration rates will be 99-100% worldwide.

Issac: Several countries in Africa will have nationally integrated health information systems that support many services at the point of care, they will be phasing out use of paper. Politicians in the US will be scratching their heads, wondering why throwing so much money at health IT problems didn't solve them, and starting to take seriously the innovation happening in Africa.

Download full transcript.

Add your voice to the conversation by commenting below or on Facebook and Twitter (use hashtag #mobileinnov).

Join us tomorrow for the global Twitter chat on June 22, 2011 from 1-2:30pm EST. Follow the hashtag #mobileinnov.

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