PAIN SCALE Mobilizing mHealth Innovation for Real-World Evidence Generation Executive Summary Mobile health (mHealth) has the potential to enable progress in precision medicine and better evidence in health care. “Patient/consumer-facing” apps and wearables that collect patient-generated health data can provide a low-cost mechanism for gathering real-world, high frequency, and/or longitudinal data on measurable outcomes that people care about. As mHealth technologies are increasingly adopted for clinical use and in the consumer space, the data may be reused as part of real-world evidence generation. Such data reuse could also become an additional source of revenue for mHealth companies, beyond their value to payer or provider systems, for use in predictive analytics and improving quality of care. But despite some promising examples, the impact of mHealth on research is limited today. There is not yet a clear path for how mHealth technologies can reliably and efficiently elicit, validate, and transmit relevant data, and such data are currently not being collected on a sustained and longitudinal basis. Consequently, this is a crucial time for mHealth, with growing attention to overcoming the challenges of interoperability, common data elements, and data definitions in order to allow disparate data streams to combine to create actionable insights for improving or maintaining an individual’s health and treating disease. To accelerate the use of mHealth for research on medical treatments, the Duke-Margolis Center for Health Policy convened a working group of experts from throughout the healthcare and mHealth ecosystem to form a set of recommendations that will help: • Create collaborations between the patient, clinical, and research communities as well as mHealth companies to advance the science on collecting and using mHealth data for evidence generation; • Enable mobile health developers and companies to build their products on a strong standardized base in the pre-competitive space; and • Ensure that users of patient/consumer-facing technologies understand and can more efficiently consent to how their data may be used, and are kept informed of research developments resulting from their data donations. The working group made the following broad recommendations; below each is an example of a specific action step aimed at improving the collection and use of data for high-priority research and public health activities. 1. Establish a Learning mHealth Research Community to advance the development and use of patient/consumer-facing mHealth technologies in evidence generation. Publish initial priority list of areas where mHealth could have a large impact. 2. Help mHealth companies save development time and increase marketability with a research-capable design that returns actionable insights to patients and/or consumers to encourage long-term use. Use entities such as Open mHealth, Github, ResearchKit, ResearchStack, etc. that provide open source information on technology standards. 3. Ensure efficient access to well-characterized, standardized, and robust user-generated health data. Utilize continued development of standards through trade organizations such as the Consumer Technology Association’s standards for physical activity and sleep monitors. 4. Use mHealth technologies to communicate with study participants to provide meaningful and understandable feedback of study progress and research results. Academic journals should allow researchers to send study participants any resulting articles for free. 5. Use mHealth to promote easier participation in research through the awareness and adoption of standardized approaches for informed consent and patient privacy. Adopt reusable mobile-ready frameworks such as the Eureka Research Platform, Hugo, and Sage’s Participant-Centered Consent toolkit for enrollment and informed consent. More action steps are listed in the main document. Following the Action Plan, there is an extensive series of appendices which are meant to serve as a resource guide of current efforts in each space. Duke-Margolis Center for Health Policy | healthpolicy.duke.edu i Authors Ashish Atreja, Chief Technology Innovation and Mohit Kaushal, Private Investor Engagement Officer, Sinai AppLab John Mattison, Chief Health Information Officer David Bates, Chief, Division of General Internal and Assistant Medical Director, Kaiser Permanente, Medicine and Primary Care, Brigham and Women’s SCAL Hospital & Medical Director, Clinical Quality and Michael McConnell, Head of Cardiovascular Health Analysis, Partners Healthcare System, Inc. Innovations, Verily Life Sciences & Professor of Seth Clancy, Senior Director, Global Health Cardiovascular Medicine, Stanford University Economics & Reimbursement, Edwards School of Medicine Lifesciences Gregory Pappas, Associate Director, National Gregory Daniel, Deputy Director, Duke-Robert J. Evaluation System for health Technology (NEST), Margolis, MD, Center for Health Policy & Clinical Center for Devices and Radiological Health, Food Professor, Fuqua School of Business, Duke and Drug Administration University Bakul Patel, Associate Director for Digital Health, Megan Doerr, Principal Scientist, Governance, Center for Devices and Radiological Health, Food Sage Bionetworks and Drug Administration Patricia Franklin, Professor, Orthopedics and Ravi Ramachandran, Senior Director, Business Physical Rehabilitation, University of Partnerships and Solutions, PatientsLikeMe Massachusetts Medical School & Senior John Reites, Chief Product Officer and Partner, Scientific Director, FORCE-TJR THREAD Adrian Hernandez, Professor of Medicine & Vice Anindita Saha, Director, External Expertise and Dean for Clinical Research, Duke University School Partnerships, Center for Devices and Radiological of Medicine Health, Food and Drug Administration Martin Ho, Associate Director, Quantitative Kevin Weinfurt, Professor, Department of Innovation, Center for Devices and Radiological Population Health Sciences, Duke University Health, Food and Drug Administration Editors Gregory Daniel, Deputy Director, Duke-Robert J. Mark McClellan, Director, Duke-Robert J. Margolis, Margolis, MD, Center for Health Policy & Clinical MD, Center for Health Policy & Professor of Professor, Fuqua School of Business, Duke Business, Medicine, and Health Policy, Fuqua University School of Business, Duke University Heather Colvin, Evidence Policy Initiatives, Global Isha Sharma, Senior Research Assistant, Duke- Regulatory Affairs Policy & Intelligence Medical Robert J. Margolis, MD, Center for Health Policy, Devices ACRO Services Corporation, providing Duke University services for Johnson & Johnson Jonathan Bryan, Research Assistant, Duke-Robert (formerly Duke-Margolis) J. Margolis, MD, Center for Health Policy, Duke Christina Silcox, Research Associate, Duke-Robert University J. Margolis, MD, Center for Health Policy, Duke University Duke-Margolis Center for Health Policy | healthpolicy.duke.edu ii Acknowledgements The Duke-Margolis Center for Health Policy would like to thank everyone who contributed their time and expertise in the development of this Action Plan. This Action Plan would not have been possible without the dedication, collaboration, and feedback of our working group. The Duke-Margolis team also held many informational meetings and calls with various stakeholders across the digital health spectrum. We are extremely grateful for their time and thought-provoking feedback throughout the past months. We thank Ellen De Graffenreid, the Duke-Margolis Center’s Director of Communications, for her editorial support. And we would like to extend a special thank you to Marat Fudim, a cardiology fellow at Duke University, for his help collecting the resources and examples listed in the appendices. Finally, the Center would like to thank and acknowledge the editorial comments of the FDA CDRH staff. Any opinions expressed in this paper are those of the authors, and do not represent the views or policies of HHS or FDA. Funding for this meeting was made possible by the Food and Drug Administration through grant 7U01FD004969. Views expressed in the written materials and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services nor does any mention of trade names, commercial practices, or organization imply endorsement by the United States Government. About the Duke-Margolis Center for Health Policy The Duke-Robert J. Margolis, MD, Center for Health Policy, founded with a gift from Duke University School of Medicine alumnus Robert J. Margolis and his wife Lisa, connects the intellectual resources at Duke with policymakers and policy analysts in the public and private sector. Disciplines involved in the Duke-Robert J. Margolis, MD, Center for Health Policy will include business, biomedical research, clinical care, public policy, global health, law and other areas. The Duke-Margolis Center has staff and offices in both Durham and at Duke’s center in Washington, D.C. It has participation from faculty and staff at Fuqua, Sanford School of Public Policy, School of Medicine, School of Law and other units, and collaborates with experts and health care reformers from across the country and around the world. The center’s activities include serving as a hub for translational policy research and analysis — that is, for supporting the movement of promising ideas in health reform into the implementation of effective policy. Duke-Margolis Center for Health Policy | healthpolicy.duke.edu