The worldwide prevalence of mobile phones makes them a powerful platform for providing individualized health care delivered at the patient’s convenience. They have the potential to extend the health care interaction from a brief office visit to a continuous monitoring via body sensors of either a specific healthcare parameter or with multiple sensors in wireless body area networks. Remote data collection by way of mobile phones in underserved areas allows for better management of public health and provides the opportunity for timely intervention. Published data showing benefits specific to otolaryngology are primarily in remote consultation, body sensors specific to balance, and appointment compliance.
Globally, cell telephones are among the most ubiquitous technologies today. A staggering 60% of the world’s population owns a cellular telephone, a statistic surpassing even ownership of televisions. Mobile technologies have become the platform of choice for consumers and industry. With 5.3 billion mobile subscribers as of 2010, its presence is so significant that it surpassed the number of people in the world with toothbrushes by twofold. With greater access to mobile telephones including rural areas, the potential of lowering information and transaction costs to deliver health care improves. Mobile technologies power the tablet or slate computer movement, which has expanded at a dramatic rate in the past few years. Coupled with this movement is the application store experience, which allows the user to personalize and customize mobile technologies for their specific needs. Paralleling this popularity, the use of cellular telephones in medicine is expanding. To date, there is a paucity of objective outcome data available on the efficacy of cell phones as an aid in telehealth, medicine in general, and otolaryngology specifically. Anecdotal data suggest, however, that although many applications of cell phone technology are quite simple, they are nevertheless effective in meaningful ways that can impact patient outcomes.
The healthcare community, which includes the military health system, now recognizes that mobile devices represent an enormous opportunity for healthcare outreach. Social networks, too, now go hand-in-hand with mobile devices. Statistics show that more people access social networks using the mobile World Wide Web than they do using desktop computers. There are concerns using social networks because of the lack of confidentiality of these networks, but newer social networks, such as Google+, address some of these privacy concerns making them potentially more useful in medicine. There is some age disparity in the use of mobile technologies, but still overall mobile devices are the tool of choice for communication in the virtual sphere. As a result, cell phones represent a tool that can reach a very substantial patient population.
Strong evidence exists to suggest that mobile health technologies can help to bring about behavior change by impacting healthcare challenges, such as smoking cessation, diabetes, and appointment attendance. Applications for cell phone platforms are emerging that enable clinical consultation, patient and provider education, research, biosurveillance, and disease management. Leveraging mobile devices in health care has been limited because of challenges in integrating their use in routine clinical practice and the security concerns of these devices on the commercial and military networks. Most applications have relied on mobile device primary function of communication via voice, short message service (SMS) text, and email. To deliver better value and improve access, healthcare organizations need to invest in commodity mobile technologies and modernize the clinical mobile experience that supports a variety of uses as a common service:
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Point of care
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Emergency response systems
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Human resources coordination, management, and supervision
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Mobile synchronous (voice) and asynchronous SMS telemedicine diagnostic and decision support to remote clinicians
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Clinician-focused, evidence-based decision support
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Pharmaceutical supply chain integrity
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Patient safety systems
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Clinical care and remote patient monitoring
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Health extension services
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Health services monitoring and reporting
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Health-related mLearning for the general public
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Training and continuing professional development for healthcare workers
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Health promotion and community mobilization
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Support of chronic conditions
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Remote data collection, such as industrial hygiene assessments
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Medication monitoring for dose adjustment and side effect documentation.
Federal government funding to advance mobile health
As mobile health use evolves from preclinical encounters (wellness tips; appointment reminders; and behavior change notices, such as smoking cessation) between the patient and the healthcare team, to clinical encounters (ie, medication change, subspecialty referrals) where treatment and management decisions are made, it is critical to document this encounter in the electronic health record (EHR). The Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009 was established to accelerate the adoption of EHRs (meaningful use) and spur innovation in healthcare delivery by establishing financial incentives ($19–$27 billion) to practices and hospitals. The HITECH Act is an aggressive and deliberate effort by the government to introduce health information technology into clinical settings with a deliberate goal of producing a safer, more efficient, more reliable, and more effective healthcare delivery system. Widespread adoption of EHRs is a prerequisite to widespread use of mobile health for clinical encounters. Complementing and further supporting HITECH, is the Affordable Care Act of 2010, which underscores the importance of health information technology in achieving goals related to health care quality and cost. This Act established the Center for Medicare & Medicaid Innovation to test innovations in care delivery and payments in diverse practices and will further potentially aid the widespread adoption of mobile health in clinical practice.
Mobile devices in health care: a survey of current work
In telemedicine, and in particular, teleotolaryngology, cell phones are being used for some of the most fundamental capabilities, such as remote consultation. Camera telephones have been used, for instance, to send photographs of nasal fractures to specialists for consultation. Mobile telephones equipped with cameras have also enabled clinicians to transmit radiologic images for quick assessment in head and neck emergency situations.
The availability and user acceptance of cell phones have allowed them to impact health care in ways that go well beyond traditional teleconsultation. Mobile health care using cell phones and other mobile technologies can be broken down into four key areas: (1) mobile health applications for patients, (2) remote data collection, (3) remote monitoring and diagnostics, and (4) decision support and mobile learning. A number of large-scale mobile health efforts are underway.
Mobile Health Applications for Patients
Txt2stop involved 5800 smokers from the United Kingdom in a randomized single-blinded study of smoking cessation SMS text messaging versus standard smoking cessation treatment and demonstrated a modest but statistically significant difference in smoking cessation in the SMS text group (cessation chemically verified at 6 months). An earlier (2009) Cochrane review of mobile telephone–based smoking cessation studies had not shown a long-term difference. Many medical systems offer the option of voice messages or SMS text messages as appointment reminders.
The US Military medical facilities have implemented programs that use personal cell phones to remind patients of appointments, to disseminate health and wellness information, and to gather important information from patients that can alert clinicians in real time to their status. At the Walter Reed Army Medical Center, cell phones are being studied as a tool for improving adherence to diabetes therapy. The US Army’s mCare provides secure SMS text messaging for patients, particularly targeting posttraumatic stress and traumatic brain injury patients. This program delivers appointment reminders to these patients, who often find the task of keeping multiple medical appointments challenging. In addition, mCare provides wellness information and disseminates general announcements pertinent to the patient. Initial data suggest that this very simple tool has had a positive impact on the military traumatic brain injury and posttraumatic stress patient population, mainly by increasing their likelihood of continuing and complying with treatment. As part of its health diplomacy, the US Army has initiated efforts to offer a SMS texting program targeting public health (particularly pediatric and maternal–fetal care) to assist developing nations. In the otolaryngology literature, use of text messages has reduced missed appointments at an outpatient clinic.
In February 2010, the National Healthy Mothers Healthy Babies Coalition initiated the Text4baby program, a free mobile information service that provides health information to more than 131,000 pregnant women to promote maternal and child health. Text4baby messages also tell women how to access public clinics and support services for prenatal and infant care.
Remote Data Collection
Cell phones have evolved into tools for remote data collection, which can be especially useful in developing countries where a cellular infrastructure exists, even if other capabilities are lacking. Healthcare workers at the local level can upload health data by mobile device allowing disease surveillance, timely public health decisions, and feedback to the local healthcare worker via SMS text. The United Nation foundation global solutions Web site lists 15 active remote data collection projects. Examples include AIDS monitoring in Rwanda, malaria monitoring in Mozambique, a mobile-based primary healthcare management in India, and a community health information tracking system in the Philippines. No specific examples for otolaryngology were available, but one could imagine remote hearing testing or data on head and neck cancer uploaded to a central database to provide an accurate measure of the disease burden with SMS text back to healthcare workers providing advice to manage that burden.
Remote Monitoring
Remote monitoring with mobile telephones and coupled sensors or wireless body area networks allows for objective physiologic measurements outside of the medical clinic with potential real-time feedback. The rapid growth in physiologic sensors, low-power integrated circuits, and wireless communication has enabled a new generation of wireless sensor networks that can be used for rehabilitation or early detection of medical conditions. Objective mobile health monitoring will be further advanced through the integration of wireless communications with miniaturized biosensors that are either worn externally or implanted. Biosensors currently measure and track specific body physiologic parameters, such as electrocardiogram, temperature, heart rate, blood pressure, weight, breathing, blood sugar, and electroencephalogram waves. The most likely wireless communication, Bluetooth or ZigBee, will communicate with a mobile device, creating a body area network to represent the communications on, in, and near only the body. Captured physiologic data will be transmitted wirelessly from the sensors to a mobile device, which then transmits the data over the Internet or a wireless telecommunications system to a remote computer, monitoring system, concerned family member, or primary healthcare provider.
Challenges in full-scale implementation include interoperability of data across different wireless networks, security of data transfer to maintain HIPAA standards, sensor validation in variable power settings, and simplicity and ease of use of system design.
Although a wireless body area network can involve multiple sensors it can also be a simple as recording exercise data using a shoe-based GPS system, such as the Nike iPhone application to monitor the activity level for a weight loss program. Current efforts in otolaryngology have focused on balance. Researchers at the University of California Los Angeles’s wireless health institute and the Massachusetts Institute of Technology have developed sensors incorporated into the insoles of patients’ shoes that record balance and gait parameters. The Massachusetts Institute of Technology (through US Army-DARPA funding) has developed a foot strike power generation system that promises to supply power to the system once reliability issues are solved. The University of California Los Angeles insole effort ( Fig. 1 ) is currently in its third-generation of insole that includes 40 pressure sensors and an accelerometer, and is actively undergoing clinical testing (Majid Sarrafzadeh, PhD, personal communication, 2011). This technology provides an object measure for home vestibular therapy not currently available.
