Notification Fatigue

This subject popped up as a side conversation during a conference call I was on today. I was being asked my opinion about how to avoid “notification fatigue”. You know, when a system or systems provide so much feedback to a user that they effectively shut down and become immune to the notices.

As more and more medical services attempt to grab a patient’s attention with important health information, or perhaps even wrestle the patient’s attention away from somewhere else, like YouTube videos and Facebook friends, we will be facing a daunting challenge. This is where mHealth can play a vital role, for only a mobile device is accessible to the patient nearly all the time has the chance to grab their attention precisely when information is most relevant to them.

I’m afraid though, that the tools needed to do this well are going to run full speed into the HIPAA wall. Understanding relevancy for a patient requires detailed knowledge about their habits and behaviors, like what they are browsing and when. And once collected in the context of a patient – provider interaction, I expect that HIPAA and other statutes will have something to say about how or even if it can be used.

I hope to explore more about this in the coming months.

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The Jetsons Never Predicted Mobile Phones

I was watching an episode of the Jetsons with my five year-old the other day, when it occurred to me that, of all the futuristic inventions the creators imagined, the cell/mobile phone wasn’t among them.

It’s true — even with all the advanced technology that George, Jane, Judy, Elroy, and Astro had at their disposal, like anti-gravity belts, nuclear-powered flying cars that fold into briefcases, robot maids, automated closets, pneumatic tube people-movers, and the awesome Food-a-Rac-a-Cycle, they had no portable communications devices.

In this episode, Jane needed to tell George about something after he had already left for work. And even while he was flying in his plutonium-powered car, Jane had to wait until George was at work before dialing him up on the video phone. Amazing …

It made me wonder if mobile communications technology really is so outside of traditional human experience that its adoption in areas like mHealth is slowed by a basic,  fundamental incompatibility with humans that we’re still working through 27 or so years since the first cellular telephone system was commercially available in the US.

Why Smartphones Are the Wrong mHealth Platform

(At least right now …)

I’ll begin with the iPhone, because it pains me every day that this device is so hyped and has attracted such a cult following in the mainstream media. There is a simple three word reason that the iPhone will never be a useful mHealth device:

Non Replaceable Battery.

Can you imagine the scenario where a patient comes to rely on their mobile device for something like carbohydrate calculations and recording blood sugar readings and insulin use, but then has to send their phone back to Apple for two weeks so the battery can be replaced?

Personally, I find it irresponsible for anyone to try to create any kind of health care application on a piece of hardware with such a glaring flaw. Fine perhaps if you intend to cater only to the boutique client who has enough money to drop $500 every 18 months when their battery starts dying so they simply upgrade to a new phone. But for the average patient — developing on the iPhone is simply unconscionable.

While we’re on the subject of the iPhone, here’s reason number two that the iPhone is a poor development platform: the App Store. Health care is best when decisions are made between a patient and their doctor. And judgments of app effectiveness are best made in the light of day, in public view, with a transparent process. So explain to me how the App Store and Apple’s closed, incomprehensible acceptance process furthers those two goals. It is already painful enough that caregivers and patients have their treatment choices limited by insurance companies; to insert a technology company and an opaque process for making applications available into that system in no way benefits the patient. Now in addition to insurance restrictions, I’m supposed to be happy that my choice of health care technology is limited by a bunch of twenty-somethings sitting in a room at Apple allowing or denying the availability of apps based on their own reasons? Please.

In addition to these two uniquely Apple flaws, smartphones in general suffer from one additional glaring problem: carriers and their plans and contracts. Assuming for a minute that we can get past the different technologies (CDMA/GSM) running on different networks, the basic idea of the discounted phone and lock-in contract is stifling this mHealth industry. Imagine for a moment the day when we have to add the duration of a patient’s cell phone contract into the treatment calculus. “Ms. Jones, I recommend highly this wonderful application which will allow you to share with me in real-time your condition so we can quickly adjust your meds any time day or night.” “Thanks doc, but I’m stuck with my plain old cell phone for another 14 months until my contract expires. Maybe then.”

Don’t get me wrong … I think that in ten or maybe even five years, smartphones will be ubiquitous and critical components of our health care. But right now, the barriers are too great to take them seriously. Perhaps Google can force change upon the carriers with their phone store, but even the Nexus One suffers the same 2-year contract lock-in problem unless you’re willing to shell out $500+ for it. But, what I can do for patients today, or next month, or even this year, isn’t much.

Internet Usage Among Seniors and Patients

I think it’s only fitting to begin this blog with some real data. Probably one of the most comprehensive and trusted (at least by me) sources has been the Pew Internet and American Life Project from the Pew Research Center. Lead by Susannah Fox, the project produces some of the most pertinent data related to Internet usage I’ve ever found. And one of their latest reports is enlightening.

I will first confess a bias … in many places within the online mHealth community, people are encouraged to ignore the perception that older people don’t use the Internet. I’ve always felt that advocates for this perspective are letting their availability bias cloud their judgment. Everyone knows or has a progressive older relative. You know, the iPhone using Grandma, or the Skype-using Grandpa. But my job offers me the opportunity to interact directly (face-to-face or via phone) with dozens of real patients living with one or more chronic conditions (usually diabetes or hypertension) and indirectly with hundreds more. And my experience tells me a few things.

  • These patients are usually older.
  • Few use a computer.
  • Fewer still are interested in learning to use a computer or smartphone.
  • Among those who use a computer, usually it’s only for a specific task like e-mail. Introducing new uses is difficult.

So I’ve carried around a bit of guilt, wondering if I was biased or if our population of patients was somehow different.

In December, Susannah Fox posted on the e-Patients.net blog something that helped confirm my impression:

My next report will focus on internet use among adults living with chronic diseases (with a special focus on diabetes, heart conditions, lung conditions, high blood pressure, and/or cancer).  The last time I took a look at this group was in 2007, when we asked a broader question to define e-patients living with a disability or chronic disease. No matter which way we slice the population, though, I can tell you that internet access is still low among people challenged by health problems. Not much has changed in two years.

This was a disappointing, though expected statement for me. And when Pew released the full report a few days ago, I believe that my impressions were correct — in the population of older, possibly chronically ill Americans, Internet usage and mobile technology usage is low.

I encourage you to read the report. One additional data point important for mHealth is:

just 16% of U.S. adults age 65 and older go online wirelessly, via a laptop or handheld device. By contrast, 55% of all adults connect to the internet wirelessly.

This is not as discouraging at it seems at first. Rather than give up, this information has helped confirm my strategy. I interpret these numbers in the context of “active” Internet users or “active” wireless users. I still believe deeply in the power of mHealth and wireless technologies to change the lives of chronically ill patients and to improve the relationship between patients and their providers, but I think the immediate future requires passive mHealth devices, rather than active mHealth solutions. Think of the Kindle from Amazon … how many users do you think really know that the Kindle is powered by the Sprint EVDO data network? I’ll bet less than 30% … yet the device is a paradigm-shifting mobile device. Kindle owners don’t have to care about the wireless connectivity … after an initial activation, it just works wherever there is signal. I believe the immediate future of mHealth needs to work like this. Healthcare devices need to just work with a minimum of action required by the patient.