Executive summary By leveraging the power and reach of mobile communications, mHealth makes it possible to provide a more versatile and personalized approach to . However, in order for mHealth to reach its full potential, four critical dimensions The four dimensions must align: people, places, payment, and purpose. People: Demographics of effective mHealth: A nuanced understanding of demographics such as age, gender, and income can point to technology preferences and help drive customization and targeting of People, places, users’ mHealth experiences. Places: Local infrastructure The convergence of infrastructure needs (reliable local networks – cellular, broadband payment, and purpose and wireless, download speeds, and bandwidth capacity) and rapid technological development may be a tipping point for mHealth adoption. Payment: Reimbursement and regulatory The promise of mobile health (mHealth), the Value-based reforms are prompting health care organizations to 1) find more efficient ways to improve care while increasing quality; 2) expand care delivery use of mobile devices to support the practice outside the hospital and physician office; 3) facilitate patient-provider connectivity of medicine and , is profound “anytime and anywhere”; and 4) increase patient engagement. Addressing privacy and security concerns, as well as reimbursement approaches and regulatory but, as yet, unrealized. mHealth strategies, consistency across jurisdictions, should remove several existing barriers to adoption. however, are not “one-size-fits-all.” Purpose: Disease dynamics Fitness, wellness, care provision, disease management, and complex case management can be supported by mHealth functionality, but the approach has to #mHealth4D fit the condition.

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Key takeaways Figure 1: The four dimensions of effective mHealth Health care organizations – providers, payers, and life sciences companies – should consider each of the four dimensions of mHealth as they weigh market entry (See Figure 1). Among important considerations: • Personalize the consumer’s experience. mHealth offers tools – consumer engagement strategies, retail capabilities based upon mobile platforms and data analytics, digitization of an individual’s wellness and health care needs, and more – that can enable competitive differentiation by creating personalized solutions that help drive Payment: People: consumer loyalty. mHealth Reimbursement Demographics • Keep it simple. mHealth functionality should be and regulatory easy to use and akin to users’ mobile experiences in hospitality, retail, travel, and banking. • Pay attention to privacy and security. mHealth technologies and permeable boundaries among Places: Purpose: existing and new entrants in the health care Local infrastructure Disease dynamics ecosystem increase the complexity of managing protected health information (PHI). Organizations need to be secure, vigilant, and resilient in the face of threats to information security.

2 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS People: Demographics Figure 2: Mobile device ownership (2012-2013) A nuanced understanding of demographics such as age, gender, and income can point to technology Cell phone ownership preferences and help drive customization and Age 2012 2013 % change 2012-2013 targeting of users’ mHealth experiences.1 mHealth programs should be designed to be operable via 18-29 95% 97% 2% multiple communication platforms and channels such 30-49 91% 95% 4% as phones, tablets, , and social media. 50-64 83% 89% 6% 65+ 65% 77% 12%

• The platform for mHealth already exists. ownership Smartphone ownership in the United States is at a high and still growing.2 Almost all U.S. adults own Age 2012 2013 % change 2012-2013 a cell phone, half of which are .3 And, 18-29 66% 79% 13% over two in five (42 percent) own a tablet.4 On 30-49 59% 67% 8% average, a U.S. adult carries three devices, with the 50-64 34% 45% 11% 5 most popular being a smartphone. Mobile devices 65+ 11% 18% 7% are heavily used for connectivity; Internet usage Tablet ownership among U.S. adult owners is now at 63 percent, twice as high as in 2009, and at least Age 2012 2013 % change 2012-2013

half of owners have downloaded an application 18-29 20% 34% 14% 6, 7 (app). One in three U.S. consumers has used their 30-49 26% 44% 18% 8 mobile phone to look for health information. 50-64 14% 32% 18% 65+ 8% 18% 10%

Source: Pew Summer Tracking Survey 2012: PEW Mobile Tecchnology Fact Sheet 2014: PEW Tablet Ownership 2013

3 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS • Consumers have a growing interest in mHealth. Millennials (born 1982-1994), in particular, are already dabbling in the technology. They demonstrate a generational difference in interest – twice as many Millennials as overall respondents in a recent survey said they downloaded a health tracking app (19 percent of Millennials vs. 10 percent of all respondents). Similarly, one in four Millennials has used smartphones and tablet apps to manage and monitor their fitness and health improvement goals such as exercise or diet (25 percent of Millennials vs. 17 percent of all respondents).9 • Smartphone ownership by U.S. adults aged 50-65 years increased from 34 percent to 45 percent between 2012 and 2013 (Figure 2). Over the same period, smartphone ownership by Seniors (aged 65+ years) grew by seven percent. Baby Boomers (born 1946-1964), in particular, are expected to combine an interest in technology with substantial purchasing power to generate the fastest year-on-year growth in smartphone penetration in 2014.10 Around one in five Boomers has never downloaded an app vs. one in 10 of all age groupings. This may present both a challenge and an opportunity to carriers and health providers to engage this group in mHealth-oriented technologies and behaviors.10

4 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS In a health care environment which is rapidly moving Figure 3: Six health care consumer segments – Online & Onboard towards being patient-centered, different consumer segments will likely demand that mHealth programs and delivery channels be tailored to their distinct user preferences. • Deloitte has identified six unique consumer health Sick & Savvy Out & About consumes considerable independent; prefers care segments that navigate the health care system health care services alternatives; wants to in very different ways (Figure 3). One segment, & products; partners customize services Shop & Save with physician to make active; seeks options and “online and onboard,” represents a more “active” treatment decisions switches for value; saves % for future health costs health care consumer which, in comparison with % 9 4% 18 % other segments, has a strong preference to use Millennials 14 online tools and mobile applications to locate providers and compare treatment options and 19 % Gen X provider qualities. % 17 34% • In 2012, just under 20 percent of the younger 15 % generations, Millennials (born 1982-1994) and Gen Online & Onboard Boomers X (born 1965-1981), and around 15 percent of the online learner; happy with care Casual & Cautious older generations, Baby Boomers (born 1946-1964) but interested in alternatives % 22% not engaged; no current & technologies 14 need; cost-conscious and Seniors (born 1900-1945), fell into the “online Seniors and onboard” segment.11

Content & Compliant happy with physician, hospital and health plan; trusting and follows care plans 5 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Places: Local infrastructure Figure 4: LTE coverage map as of April 2014 • A lack of reliable local networks – cellular, broadband, and wireless – currently limit mHealth capabilities. However, increasing download speeds and bandwidth capacity should enable mHealth programs to leverage more advanced mobile functions. Weak signal Strong signal • As mobile devices and their apps become more sophisticated, consume more data, and are almost constantly in use, they will likely require better, faster, and more widespread networks. Advances in technology, lower- priced subscriber plans, and longer device battery life have broadened consumer access to mHealth. The growing size of files as the transfer of technologies such as imaging products and remote become more prevalent is likely to drive future demand for bandwidth. • Phone carriers are building out the next generation of networks, 4G LTE, which will likely enable faster response times, help resolve latency issues, and support higher-bandwidth applications such as video and high-definition imagery. However, this build-out will likely take time and large gaps currently exist (Figure 4). • Telemedicine technologies offer access solutions for rural and underserved areas; however, many of these areas have broadband limitations. Physicians with small practices in remote areas have been identified as a key group limited by broadband gaps that render them unable to effectively use Source: OpenSignal.com mHealth technologies in an environment ideal for mHealth.12

6 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Health care systems’ current readiness to manage and respond to incoming clinical • To overcome continuity problems and data loss caused by “dead-spots” in data may slow realization of mHealth’s full potential. elevators, long corridors, and stairwells, health care facilities are investing in 17 • Interoperable systems and analytic capabilities are essential to enable health care enterprise-wide mobility solutions for continuous wireless connectivity. organizations to utilize incoming streams of data. For example, mobile access • Connectivity is critical for mobile outreach programs (e.g., mobile emergency to patient information was found to improve accessibility, productivity, and response programs) that need to capture data in real time and upload it to an workflow in a Department of Veterans Affairs’ (VA) 2011 mobile health clinician EHR. For example, a mobile crisis team used a solution that integrated pilot. An extension of this study will test how a suite of VA clinician apps built with broadband connectivity to ensure devices were always connected and around mobile access to patient information affects accessibility, productivity, allowed data to be entered real-time into a patient’s EHR. This resulted in better workflow, and communications across VA care teams.13 care coordination and improved billing accuracy.17 • Modeling of widespread adoption of interoperability among medical devices, electronic health records (EHRs), mobile devices, and health information technology (HIT) systems projects savings of around $30 billion per year.14 In one example, the VA-originated web-based program allows patients to access their medical records, create portable medical histories, self-report health metrics, and view claims. Initiatives such as Blue Button are intended to facilitate information-sharing across platforms with providers, improve care coordination, and increase patient engagement.15 • Implementing a suite of Internet, mobile, and video tools at Kaiser Permanente Northern California (KPNC) revealed that operating as an integrated health care system improved information flow across patient care settings, administrative functions, and payment systems.16

7 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Payment: Reimbursement and regulatory A recent study found that four in Early mHealth models were primarily unsuccessful because of reimbursement issues rather than technological ones.18 Payment innovations were difficult 10 U.S. hospitals have adopted due to the chronic nature of conditions, scope of care needed to address them, and mHealth management challenges. In addition, co-morbidity (a broadly defined category was often misunderstood or overlooked, understating the true savings that which incorporates mHealth). Factors mHealth could bring. Value-based reforms that reward lower costs and better health outcomes may help advance the business case for mHealth. influencing adoption included market • mHealth’s communication, coordination, monitoring, and data collection capabilities may provide tools to help achieve the goals inherent in new features (highly competitive, rural rather service delivery models such as accountable care organizations.19 These new than urban), complexity of services, delivery models and reimbursement reforms such as bundled payments are predicated on achieving quality outcomes against evidence-based and regulatory oversight such as standards. Payments are based on evaluations of clinical processes, patient experiences, outcomes, and efficiencies against industry benchmarks and payment and licensure restrictions. base thresholds, including incorporating data flowing both remotely and at Source: Milstein-Adler, J.,Kvedar, J., & Bates, D.W. (2014) Telehealth among the point of care. US hospitals: Several factors, including state reimbursement and licensure • Health care providers want to harness the power of mobile payments. Since policies, influence adoption. Health Affairs. 33(2), 207-15. doi: 10.1377/ providers collect between 35 percent and 65 percent of patient payments hlthaff.2013.1054 and 30 percent of provider revenues are derived from patient payments, smartphone-based systems offer an attractive payment option.20 A next- gen system might incorporate a self-service web portal that provides patients with access to their financial and clinical information and facilitates mobile payments.

8 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS • Regulations protecting the privacy and security of personal information, • Consumer concern about the amount of personal information captured, stored, malpractice liability regulations, and little consistency between licensure and and shared by mobile devices is growing. A study found that 86 percent of reimbursement laws across states and countries are barriers to extensive mHealth consumers had taken steps to cover their digital footprints in 2013.26 The study adoption.21, 22 A recent policy proposal seeks to provide guidance to state medical also noted growth in consumers’ use of privacy tools that delete and block boards for regulating the use of telemedicine and to remove regulatory hurdles tracing cookies and encrypted messaging systems that block browsing and web to widespread adoption of telemedicine technologies. These guidelines, in search history. part, require that physicians validate the patient’s location and identity, disclose the provider’s identity, and obtain appropriate consent prior to providing As more advanced apps reach the mHealth market, either acting as medical devices telemedicine services. 23 or providing decision support, they will fall under increased regulatory scrutiny. In September 2013, the FDA adopted a risk-based approach to monitoring mobile mHealth technologies and permeable boundaries among existing and new entrants medical apps and released guidance for a subset of apps considered to be medical in the health ecosystem increase the complexity of managing PHI and compound devices that could potentially pose a threat to patient safety if their functionality an already challenging issue for industry stakeholders. failed (See page 10). The Food and Drug Administration Safety and Innovation • Under the Health Insurance Portability and Accountability Act (HIPAA) Omnibus Act (FDASIA) (2012) required the U.S. Department of Health and Human Services Rule (2013), health care organizations hold substantial responsibility for (HHS) to implement a strategy and recommendations for a risk-based framework protecting PHI. This includes being prepared for the HIPAA audit program, where for health IT, encompassing mHealth. In April 2014, HHS, in conjunction with health care organizations can expect to be measured on, among other things, risk three other federal agencies, outlined four key priority areas in the proposed analysis procedures and safeguards to prevent data breaches.24 strategy: promote the use of quality management principles; identify, develop, and adopt standards and best practices; leverage conformity assessment tools; • Broad-based enterprise risk management policies should address government and create an environment of learning and continual improvement. The proposed requirements such as HIPAA regulations and the Food and Drug Administration strategy and recommendations identify three categories of health IT functionality: (FDA) guidance for managing cybersecurity in medical devices,25 as well as user 1) administrative functionality: no additional FDA oversight needed; 2) health trends such as “bring your own device” (BYOD). management functionality: the FDA does not intend to focus on this area; 3) medical device functionality: FDA oversight and regulation needed.27

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STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS The U.S. FDA Guidance: Mobile Medical Applications Guidance issued by the FDA in September 2013, suggested that the FDA considers the following to be mobile medical apps subject to regulatory oversight: 1. Mobile apps that are an extension of one or more medical devices by connecting to such device(s) for purpose of controlling the device(s) or displaying, storing, analyzing or transmitting patient-specific medical device data. 2. Mobile apps that transform the mobile platform into a regulated medical device by using attachments, display screens or sensors or by including functionalities similar to those of currently regulated medical devices. Such apps are required to comply with the device classification associated with the transformed platform. 3. Mobile apps that become a regulated medical device (software) by performing patient-specific analysis and providing patient- specific diagnosis or treatment recommendations. These types of apps are similar to or perform the same function as those types of software devices that have been previously cleared or approved.

Source: U.S. Department of Health and Human Services Food and Drug Administration. Mobile Medical Applications. Guidance for Industry and Food and Drug Administration Staff. September 25, 2013. Available from http://www.fda.gov/ downloads/MedicalDevices/DeviceRegulationandGuidance/GuidanceDocuments/ UCM263366.pdf

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STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Purpose: Disease dynamics • To date, mHealth technologies have been instrumental in case management, Fitness, wellness, care provision, disease management, and complex case providing a low-cost/high-touch base for pushing out information such as text- management can be supported by mHealth functionality, but the approach has to based medication or appointment reminders and sharing data with providers.34 fit the condition. While many conditions and treatment goals may lend themselves Bundling a suite of mHealth services, including the capabilities to access their to mHealth, others may not. Certain diseases, particularly those with social stigma, personal records and to manage their care, has been found to be successful may not, or may require a more nuanced approach. in engaging patients in their own care and increasing access to providers in an integrated care organization (See page 12). • mHealth can support fitness and wellness activities and assist patients in managing certain health conditions, particularly chronic conditions such as , asthma, • Gamification, the use of gaming design to motivate and engage people in non- 35 hypertension, and HIV/AIDS, and behavioral change programs which require game contexts, forms the basis of many mHealth technologies. Scope ranges regular management, such as smoking cessation and weight loss.28-31 from general health improvement (diet and exercise) games that track progress via social networks to games designed around specific diseases. Motivational • Wearable tech products with sophisticated algorithms that gather highly accurate platforms such as Health Hero, Sonic Boom, and Keas use gamification, health-related metrics are enabling patients to become more engaged and take incentives, analytics, competition, and social networking to build a healthy 3233 a more active role in managing their health and wellness, and medical care. community. Wrist bands, jewelry, clothing, glasses, and embedded devices record data, support and encourage the wearer, and communicate data to others. Examples abound: health and fitness-related products such as Fitbit, Pebble , and Jawbone; personal devices that measure and track biometric details such as iHealth, Withings, or LifeSource wireless blood pressure monitors; and remote monitoring devices that combine advanced monitoring technology with personalized care management, such as Cardiocom’s vital sign measurement, and new technologies currently under development such as MC10 where sensors on the skin or within the body track vital statistics including heart rate, temperature, and brain activity; and digital medicines under development such as prescription medications with ingestible sensors such as those from Proteus .

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STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Kaiser Permanente Northern California’s (KPNC) flagship mobile and tablet applications allow members to exchange messages with their doctors, create appointments, view and refill prescriptions, and view their lab results and medical records. The smartphone app focuses on core transactional processes (self-service) while the tablet app focuses on prevention, health analytics, and achieving Kaiser Permanente’s “total health” vision. The apps are fully integrated with Kaiser’s system.

KPNC mobile experience: • One-fourth of the 34 million visits to KPNC’s website in the third quarter of 2013 were made to the mobile version of kp.org. • By December 2013, 42,000 patients had used a that allows users to review test results, communicate with doctors, and schedule tests. • 2.3 million telephone visits via mobile phone were anticipated to have been made by year-end 2013, compared to around 64,000 in 2008.

All data are from: Pearl. R., Kaiser Permanente Northern California: Current Experiences With Internet, Mobile, And Video Technologies. Health Affairs. 33, 2, 2014. pp:251-257

Source: KP 3.1 Mobile App by Kaiser Permanente; iTunes.com. Note: Public application and public data points shown. 12 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS A fluid environment Other dimensions of mHealth arise against the background of people, places, payment, and purpose. Mobile technologies’ functionality is applicable to a wide range of uses – from an individual’s chronic care management to complex population health analysis (Figure 5). As health care shifts towards a patient-centered and value-based delivery model, rapidly developing mHealth capabilities will likely enhance its role as a valuable partner in the transformation. Essential to the success of this partnership, of course, is the willingness of key stakeholders (consumers and providers) to embrace mHealth.

Other players in the mHealth market are emerging, each with unique opportunities and challenges. For example, and medical device companies may have technologies to offer but should consider overcoming the hurdles of incorporating their products into existing health care business models. Others such as manufacturers and developers may create promising mHealth solutions but still need to gain clinical validation and regulatory approvals. And where does the mountain of data generated by mHealth ultimately reside? Who sets and maintains standards for ownership, safe storage, access, and the right to analyze the data? Viewing mHealth from a market perspective, clear roles and rules for many participants have yet to be defined. Developers, manufacturers, and network operators are looking to identify their place in the mHealth value-chain.

13 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Figure 5: mHealth: from simple to complex Simple mHealth Complex

Single use mHealth Social mHealth Integrated mHealth Complex mHealth Focuses on a single purpose for a single Draws upon the social capabilities of Links apps and devices with the Leverages advanced integrated analytics user, typically consumer initiated. mobile technology including support, formal health care system, typically via an and provides decision support capabilities encouragement, or a sense of competition electronic health record (EHR). Exchanges at the point of care. sourced through peer and social networks. data between a consumer and health care provider with real-time monitoring and care coordination.

• Smartphone apps and wearable tech products (wrist • Gamification and competition based apps; • Mobile technology linking physician and patient (e.g., • Deep and complex data generated through mHealth bands, jewelry, clothing, glasses, and embedded incentivization programs via financial, cash-equivalent personalized and interactive administrative reminders facilitates analysis and predictive analytics at the devices) that record data, support and encourage the or rewards-based incentives to encourage users to such as appointments and prescriptions refills). population level – whether focused on optimal wearer, and encourage the user, who may decide to meet their goals. management of a specific chronic condition through to • Interfaces with organizations tailored to multiple end communicate the data to others. risk-analysis and epidemic prediction or monitoring. • Consumers likely to pursue these activities on their users – consumers, clinicians, and adminstrators. • Consumer driven, use of commercially available apps own or via such vehicles as employment-based team • Example: Data mining using algorithms to analyze data • Example: Information from multiple apps that a patient with a popular focus on wellness, diet, and exercise. challenges. collected via mobile devices to deliver insights on an uses is incorporated into the patient’s overall health individual’s patterns of behavior for individual health • Example: Fitness trackers and weight loss apps that • Example: A fitness app that tracks an individual’s record, giving a physican a more complete view of the management purposes. Data analysis oriented towards provide tips and enable users to set goals and track running statistics and shares results via a social network patient. improving public health responses through analysis weight, exercise, and calories. driven, goal-achievement challenge. of sub-populations with different risk profiles and appropriate targeting of public health interventions.

14 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Conclusion New mHealth opportunities emerge every day: personalized health care, population health, diagnostics, and management of infectious diseases and global epidemics. The platform necessary to deliver mHealth already exists, and resides in users’ hands. What remains to be firmly established is proven evidence of mobile’s sustainable value to the health care industry. Combined with technology advancements, lessons learned as research findings and clinical experiences accumulate are expected to propel mHealth towards maturity. mHealth strategies are not “one-size-fits-all” and will likely take time to develop and refine. However, health care organizations should take note: Understanding and leveraging the four dimensions of effective mHealth – people, places, payment, and purpose – is a good place to start.

15 The four dimensions of effective mHealth

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS Stakeholder considerations • Use levers such as provider incentives to promote mHealth capabilities and align with shifts in payment systems, quality improvement, and cost-saving initiatives. Health care organizations – providers, payers, and life sciences companies – should consider each of the four dimensions of mHealth as they weigh market entry. • Partner with consumers to reduce mHealth’s risks and costs and to share its benefits. Align reward programs to motivate and reward consumers for certain Health care providers behaviors or for being low-cost plan members. Similar to the safe driver rewards systems used in motor vehicle insurance, use mobile technologies to capture and • Introduce basic customer self-service options (e.g., appointment scheduling) for report data on exercise or wellness accomplishments. easy wins. Also, focus on conditions with an evidence base that supports using mobile technologies to diagnose, monitor, and treat patients. Initial choices Life sciences companies might include non-acute conditions (minor injuries/wounds, routine follow-up), chronic disease states (diabetes, depression) and post-acute care (discharge • Build better relationships with consumers through population health and medical management). compliance initiatives that are anchored by: • Enlist physician and nursing leadership to champion mHealth, shift organizational -- strategies that focus on communication channels such as social media culture, and update work flow systems. Incorporate mHealth technologies as -- consumer relationship management “business as usual” in care management models to provide an alternative to -- data analytics to identify customer preferences face-to-face consultations. Resolve reimbursement issues with payment models • Understand how stakeholders (governments, health plans, providers, patients) (criteria, rates, outcomes) for virtual visits. define, determine, and value mHealth and how various global health systems • Capture meaningful quality and cost indicators to enable economic analysis of approach the creation and regulation of mobile-enabled health care. the impact of programs such as clinical outreach and remote monitoring. • Leverage gamification and approaches based on behavioral economics to increase , brand awareness, and user preferences. Health plans/government payers • Bring payment for mHealth and virtual consultations into line with in-person consultations to stimulate investment in mHealth as a viable adjunct to bricks- and-mortar-based service delivery.

STAKEHOLDER EXECUTIVE SUMMARY PEOPLE PLACES PAYMENT PURPOSE CONCLUSION CONSIDERATIONS References

1. Rai A, Chen L, Pye J. Understanding determinants of consumer mobile health usage intentions, assimilation, and channel 18. Grigsby J, Sanders JH. Telemedicine: Where it is and where it’s going. Ann Intern Med. 1998; 129(2): 123-7. preferences. J Med Internet Res. 2013; 15(8). Epub e149. 19. Wood D. The move to accountable care organizations includes telemedicine. Telemedicine and e-Health. 2011; 7(4): 237-40. 2. Smith A. Smartphone ownership 2013. PEW Research Center Internet & American Life Project, 2013 [cited February, 2014]; 20. Sung B, Buonopane P, Rogers Z. Mobile payments. A win for patients and providers? Deloitte Consulting, 2012 [cited March, 2014]; Available from: http://www.pewinternet.org/2013/06/05/smartphone-ownership-2013/. Available from: http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_hcp_MobilePayments_081012.pdf. 3. Gartner Inc. Gartner says smartphone sales grew 46.5 percent in second quarter of 2013 and exceeded sales for first 21. Weinstein RS, Lopez AM, Joseph BA. Telemedicine, telehealth and mobile health applications that work: Opportunities and barriers. time. 2013 [cited February, 2014]; Available from: http://www.gartner.com/newsroom/id/2573415 The American Journal of Medicine. 2014; 127(3): 183-7. 4. PEW Research Center. Mobile technology fact sheet. 2014 [cited February 2014]; Available from: http://www.pewinternet.org/fact- 22. Center for Connected Health Policy. State telehealth laws and reimbursement policies: A comprehensive scan of the 50 states and sheets/mobile-technology-fact-sheet/ the District of Columbia. Sacramento, CA 2013 [cited February, 2014]; Available from: http://telehealthpolicy.us/sites/telehealthpolicy. 5. Sophos. Sophos mobile device numbers infographic. 2013 [cited February, 2014]; Available from: http://www.pcmag.com/image_ us/files/uploader/50%20State%20Medicaid%20Update%20Nov.%202013%20-%20Rev.%2012-20.pdf. popup/0,1740,iid=371072,00.asp. 23. Federation of State Medical Boards. Model policy for the appropriate use of telemedicine technologies in the practice of medicine. 6. Duggan M, Smith A. Cell internet use 2013. PEW Research Center Internet & American Life Project, 2013 [cited February 2014]; Report of the state medical boards’ appropriate regulation of telemedicine (SMART) workgroup. 2014 [cited February, 2014]; Available from: http://pewinternet.org/Reports/2013/Cell-Internet.aspx Available from: http://www.medlawblog.com/wp-content/uploads/sites/170/2014/03/CH93675319.pdf 7. Duggan M. Cell phone activities 2013. PEW Research Center Internet & American Life Project, 2013 [cited February, 2014]; Available 24. U.S. Health and Human Services Office for Civil Rights. HIPAA privacy, security and breach notification audits: Program overview & from: http://pewinternet.org/Reports/2013/Cell-Activities.aspx initial analysis. HCCA 2013 Compliance Institute, 2013 [cited February, 2014]; Available from: http://www.hcca-info.org/Portals/0/ 8. Fox S, Duggan M. Mobile health 2012. PEW Research Center Internet & American Life Project, 2012 [cited February, 2014]; Available PDFs/Resources/Conference_Handouts/Compliance_Institute/2013/Tuesday/500/504print2.pdf. from: http://www.pewinternet.org/2012/11/08/mobile-health-2012/ 25. U.S. Food and Drug Administration (FDA). Content of premarket submissions for management of cybersecurity in medical devices 9. Deloitte Center for Health Solutions. Survey of U.S. Health Care Consumers. Unpublished data. 2013. – Draft guidance for industry and food and drug administration staff. 2013 [cited February, 2014]; Available from: http://www.fda. 10. Lee P, Steward D, Calugar-Pop C. Technology, media & telecommunications predictions 2014. Deloitte Touche Tohmatsu, 2014 gov/medicaldevices/deviceregulationandguidance/guidancedocuments/ucm356186.htm [cited February, 2014]; Available from: http://www2.deloitte.com/content/dam/Deloitte/global/Documents/Technology-Media- 26. PEW Research Center. Anonymity, privacy, and security online. 2013 September. [cited February, 2014]; Available from: http://www. Telecommunications/dttl_TMT_Predictions-2014-lc2.pdf. pewinternet.org/files/old-media//Files/Reports/2013/PIP_AnonymityOnline_090513.pdf. 11. Keckley P, Coughlin S. The U.S. health care market: A strategic view of consumer segmentation. Deloitte Center for Health Solutions, 27. U.S. Food and Drug Administration (FDA), Office of the National Coordinator for Health IT (ONC) and Federal Communications 2012 [cited February, 2014]; Available from: http://www.deloitte.com/assets/Dcom-UnitedStates/Local%20Assets/Documents/us_ Commission (FCC). FDASIA Health IT Report. 2014 [cited April, 2014]; Available from: http://www.fda.gov/downloads/AboutFDA/ chs_InfoBrief_2012HealthCareConsumerSegments_011813.pdf. CentersOffices/OfficeofMedicalProductsandTobacco/CDRH/CDRHReports/UCM391521.pdf 12. Federal Communications Commission. Health care broadband in America: Early analysis and a path forward. 2010 [cited February, 28. Marcano Belisario JS, Huckvale K, Greenfield G. Smartphone and tablet self management apps for asthma. Cochrane Database of 2014]; Available from: http://download.broadband.gov/plan/fcc-omnibus-broadband-initiative-(obi)-working-reports-series-technical- Systematic Reviews. 2013; 11. paper-health-care-broadband-in-america.pdf 29. Horvath T, Azman H, Kennedy GE. Mobile phone for promoting adherence to antiretroviral therapy in patients with 13. U.S. Department of Veterans Affairs. VA mobile 2014 [cited 2014 February]. Available from: http://mobilehealth.va.gov/pilots HIV infection. Cochrane Database of Systematic Reviews 2012; 3. 14. Gary and Mary West Health Institute. The value of medical device interoperability. 2013 March. [cited February, 2014]; Available 30. Vodopivec-Jamsek V, de Jongh T, Gurol-Urganci I. Mobile phone messaging for preventive health care. Cochrane Database of from: http://www.westhealth.org/institute/interoperability. Systematic Reviews. 2012; 12. 15. U.S. Department of Veterans Affairs. Blue button 2014 [cited 2014 February]. Available from: http://www4.va.gov/bluebutton/ 31. Whittaker R, Borland R, Bullen C. Mobile phone-based interventions for smoking cessation (Review). Cochrane Database of 16. Pearl R. Kaiser Permanente Northern California: Current experiences with internet, mobile, and video technologies. Health Affairs. Systematic Reviews. 2009; 4. 2014; 33(2): 251-7. 32. Coye MJ, Haselkorn A, DeMello S. Remote patient management: Technology-enabled innovation and evolving business models for 17. Healthcare IT News. The future of wireless in healthcare: Powering the applications for 21st century care2010 [cited 2014 February]. chronic disease care. Health Affairs. 2009; 28: 126-35. Available from: http://www.healthcareitnews.com/wireless-in-healthcare 33. Kaplan RM, Stone AA. Bringing the laboratory and the clinic to the community: Mobile technologies for health promotion and disease prevention. Annual Review of Psychology. 2013; 64(471-98). 34. Santosh K, Boren SA, Balas EA. Healthcare via cell phones: A systematic review. Telemedicine and e-Health. 2009; 15(3): 231-40. 17 The four dimensions of effective mHealth 35. Deterding S, Miguel S, Nacke L. Gamification: Using game design elements in non-gaming contexts. Extended Abstracts on Human Factors in Computing Systems. 2011: 2425-8. Contacts Authors Contact information To begin a discussion on mHealth or for further Harry Greenspun, MD To learn more about the Deloitte Center information on Deloitte’s Life Sciences and Senior Advisor for Health Solutions, its projects and Health Care practice, please contact: Deloitte Center for Health Solutions events, please visit www.deloitte.com/ Deloitte LLP centerforhealthsolutions. Harry Greenspun, MD [email protected] Senior Advisor Deloitte Center for Health Solutions Deloitte Center for Health Solutions Sheryl Coughlin, PhD, MHA 1001 G Street N.W. Deloitte LLP Research Lead Suite 1200 [email protected] Deloitte Center for Health Solutions Washington, DC 20001 Deloitte Services LP Phone 202-220-2177 Quinn Solomon [email protected] Fax 202-220-2178 Digital Health Lead Toll free 888-233-6169 Deloitte Digital Christine Chang, MPH Email [email protected] Senior Manager Research Manager Web www.deloitte.com/centerforhealthsolutions Deloitte Consulting LLP Deloitte Center for Health Solutions Follow @DeloitteHealth at www.twitter.com [email protected] Deloitte Services LP [email protected] Sarah Thomas, MS Research Director Follow @DeloitteHealth on Twitter Deloitte Center for Health Solutions #mHealth4D Deloitte Services LP Acknowledgements [email protected] We wish to thank Samantha Marks Gordon, To download a copy of this report, please Lynn Sherry, Kathryn Robinson, Katelyn Mason, visit www.deloitte.com/us/mHealth4D and the many others who contributed their ideas and insights to this project. 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