Intro to mHealth

3. Alain B. Labrique, PhD, MHS, MS
Director
JHU Global mHealth Initiative (JHU-GmI)
Associate Professor
Program in Global Disease Epidemiology and Control
Dept. of International Health & Dept. of Epidemiology (jt)
Johns Hopkins Bloomberg School of Public Health
JHU School of Nursing
JHU School of Medicine (Health Informatics)

6. Maternal Mortality 2010, Worldmapper.org

7. Euclidean map of 10 million of the 850 million
Facebook users friend networks
© Paul Butler, FB
Mobile – Social Networks : New Frontiers for Global Health

8. 6.8 BILLION MOBILE-CELLULAR SUBSCRIPTIONS

9. Untethered, yet connected:
Diverse applications of ubiquitous
wireless and mobile technologies
designed to improve and
enhance health research, health services
delivery and health outcomes
mHealth

10. mHealth:The Four C’s
Harnessing ubiquitous information
and communication technology to
collect data, connect individuals to
each other and to information,
compress time and create
opportunities to intervene.

11. Global “mHealth” is a complex, diverse
development space, and is not homogenous.

13. jhumhealth.org
133 mHealth Projects at JHU, as of September 2014

14. “JiVitA” Maternal and Child Health Research Project
(WWW.JIVITA.ORG)
Public Health, Maternal and Child Health
and Nutrition Efficacy Research
to
Improve Health and Save Lives in
Bangladesh, South Asia and Globally.

16. RANGPUR

19. Rural families use mobile phones
during severe pregnancy crises
N=11,451 (2007-2010)
Source: Labrique, mHealth Summit, Washington DC, 2011

20. 168,231 Woman Survey –
Gaibandha, Bangladesh
(January-March 2012)
• 71% Households own phones
• 20% Used a phone in past 30 days for
emergency health purpose
• Phone owners 2.8 times more likely to
use phone for health call
• ONLY 23% Electricity in home!
Labrique et al., Unpublished data, mHealth Summit 2012

21. 0
.2.4.6.8
1
2008 2009 2010 2011 2012
Year
Lowest Quartile WI (n=17,176) Low Quartile WI (n=19,789)
High Quartile WI (n=6,472) Highest Quartile WI (n=1,032)
Mobile Phone Ownership by WI over Time
Household Mobile Phone Ownership over time in rural
Bangladesh, by “Wealth Index” (n=44,469)
Labrique, Tran et al, 2013 (in press)
ProportionofHHreporting“MobilePhoneOwnership”

22. Challenges in averting neonatal mortality –
being at the right place, at the right time…
•1st Day – 50% of deaths
•1st Week – 75% of deaths
Source: Lawn JE et al Lancet 2005, Based on analysis of 47 DHS datasets (1995-2003), 10,048 neonatal deaths)
“Hot Zone”

23. m-Labor
Notification
System
Pilot Study
Source: Gernand, JiVitA Data 2011
(Unpublished)
306 (88.9%)
Births Attended

25. Tremendous time and effort is invested in manual
data collection, aggregation and reporting.
Example: Bangladesh
CHW’s 19 ledgers contain 473
unique data fields.
Only 60 fields are unique,
required for a digital system
to process the same
information.

26. Census Enumeration

28. Smart Scheduling of Daily Activities,
by Priority

30. Assessing pregnancy status

32. 2.5 minutes saved for a SINGLE task
resulted in ~13 FTEs over a district.
X X /60=

33. mCARE: Integrated Community-Health Worker System to Improve
Antenatal & Postnatal Care and Increase Client Demand

34. Allow clients to report data to the system
Try it:
Text / SMS
“birth” to
1(443) 393-2228

35. 25.2
65.8
74.8
34.2
Non-intervention
group (n=135)
Intervention group
(n=193)
June 2014 - Preliminary Results:
Antenatal Care Utilization
Received Not-received

36. mTikka:
Virtual Vaccine Registry and Immunization Improvement System
Partners:
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Pregnancy Surveillance
Pregnancy registration &
survey of vaccination beliefs
Birth notification Reminder for
upcoming vaccination
EPI camp open
notification
Up-to-date vaccination
record
Timely availability of
performance indicators
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GoB National Health
Information System

37. Emerging “Lessons”
• User-centered / User-engaged design
• Extensive formative research & workflow mapping
• Iterative technical deployment and stabilization
• Early government and community engagement
• Mixed-methods evaluation
• Plan for technical failures / build-in system
redundancy
• “Control” systems to prevent & monitor misuse

38. mHealth doesn’t work in a Vacuum

39. PROVIDER
HEALTH
SYSTEM
PATIENT
Access to information
Behavior change
Activity Monitoring
Self-reported Data
Workflow management
Decision Support
Surveillance and Tracking
Remuneration / Incentives
Workforce monitoring
Real-time Data Streams
Supply-chain management

41. Providing families access to
timely information
“If you have any
bleeding during this
month, seek medical
attention right away”
Expectant women/
new mothers sign
up for service
Users receive
health-related
messages weekly
“Freemium” model to
drive coverage
“Your baby needs an
immunization this week
to stay healthy:
Available free at all
EPI clinics”

42. Photo: Text to Change

50. Healthcare Worker
Communication and Training
• Data collection and
communication tools
• Multimedia courses and lectures
• mLearning on Demand
• Interactive Quizzes
www.emocha.org

52. Project Mwana: SMS to reduce Infant HIV PCR
Turnaround Time (46%)

53. Amader Gram (Our Village) Breast Care
• Educate
• Identify
• Refer
• Track

54. SmartRegister.org

55. Emphasis on user-focused design to facilitate FHW utilization and feedback.

56. Nutrition (6) >
Integrate workforce and client training as part of the exposures

57. New frontiers!
• US FDA Approved
• 2-lead ECG

58. New frontiers!
Remote, Point-of-care Diagnostic tools
Breslauer D., et al. 2009 Mobile Phone Based Clinical Microscopy for Global Health Applications. PLoS ONE 4(7): e6320

60. Mobile-based Flow Cytometry
Ozcan Research Group (Nano-Bio Photonics / UCLA): Optical imaging techniques for point-of-care diagnostics
Hongying Zhu , Serhan O. Isikman , Onur Mudanyali , Alon Greenbaum and Aydogan Ozcan Lab Chip, 2012, Advance Article

62. 62

63. Agriculture
Health
Money
Research
m
Information
Social Networks
Entertainment

65. New paradigms for health data collection
Blood chemistry
Urinalysis
+
Medication adherence
Vital signs
Movement, activity
ECG
Body weight, mass

66. The Gartner “Hype” Cycle
Fenn J, Maskino M: When to Leap on the Hype Cycle. Gartner Group 2008.

67. “Pilotitis”

69. Healthy mSkepticism

70. The Bellagio eHealth
Evaluation Declaration 2011
“Rigorous evaluation of
e- & m-Health is necessary to
generate useful evidence and
promote the appropriate
integration of technologies to
improve health and reduce
inequalities.”

71. Bellagio Call to Action 2011
If used improperly, eHealth may divert
valuable resources and even cause
harm… implementation must be
guided by evidence…

72. “mHealth tools and interventions must be backed up
by rigorous scientific development, evaluation, and
evidence generation to enhance meaningful
innovation and best practices, and to validate tools
and methods for health professionals, consumers,
payers, governments, and industry.”

75. Why “Evidence” ?
1. Health investments in global health are driven
by more than market forces
2. Limited resources = Need for stringent, cost-
effectiveness based planning
3. Two decades of Emphasis on EBD !
4. Donors: Increased transparency / scrutiny
5. Population-side demand for improved quality
6. e-Health / ICT induced political fatigue

76. Evidence for whom ?

77. Is there evidence ? Who is asking the question ?
Improving the Evidence for Mobile Health, 2011

78. Evidence of what ?

79. “Maturity” of the mHealth Project
AmountofInformation(RED)
Threshold of “Information”
Stability Functionality Useability Efficacy Effectiveness
Methodology
Systems Engineering Qualitative Quantitative Mixed Q/Q / M&E
“Evidence” Across The mHealth Maturity Lifecycle
OF
WHAT ?
MEASURED
HOW ?

80. mHealth Technical Evidence Review Group for RMNCH
“m-TERG”
“Providing governments and implementing agencies
objective, evidence-based guidance for the
selection and scale of mHealth strategies
across the reproductive, maternal,
newborn and child health continuum”

81. INTERVENTION
OF KNOWN
EFFICACY
EFFECTIVE
COVERAGE
mHEALTH:
A Health Systems Catalyst
Jo Y, Labrique AB et al. PLOS One 2014
Shift focus from “Does mHealth work?” to
“Does mHealth optimize what we know works ?”

82. Need for Structure

83. Step 1: Develop a common
vocabulary
Help us as innovators, researchers,
funders talk about mHealth…

84. A Taxonomy for mHealth

85. What is the problem we’re trying to solve ?
AVAILABILITY
4.2.1 Supplyof
commodities
4.2.2 Supplyof
services
4.2.3 Supplyof
equipment
4.2.4 Diversityof
treatment
options
INFORMATION
4.1.1 Lack of
population
enumeration
4.1.2 Delayed
reportingof
events
4.1.3 Quality/
unreliabilityof
data
4.1.4
Communication
roadblocks
4.1.5 Accessto
informationor
data
COST
4.7.1 Expenses
relatedto
commodity
production
4.7.2 Expenses
relatedto
commodity
supply
4.7.3 Expenses
relatedto
commodity
disbursement
4.7.4 Expenses
relatedtoservice
delivery
4.7.5 Client-side
expenses
UTILIZATION
4.5.4 Lossto
follow up
4.5.1 Demandfor
services
4.5.2 Geographic
inaccessibility
4.5.3 Low
adherenceto
treatments
ACCEPTABILITY
4.4.3 Stigma
4.4.1Alignment
withlocal norms
4.4.2Addressing
individual beliefs
andpractices
EFFICIENCY
4.6.1 Workflow
management
4.6.2 Effective
resource
allocation
4.6.5 Timeliness
of care
4.6.3 Unnecessary
referrals/
transportation
4.6.4 Planning
andcoordination
QUALITY
4.3.1 Qualityof
care
4.3.3 Qualityof
Commodity
4.3.4 Health
worker
motivation
4.3.2 Health
worker
competence
4.3.6 Supportive
supervision
4.3.5 Continuity
of care

86. mHealth Strategy Intermediate Outcome Outcome / Impact
Provider Competence,
Accountability,
Effectiveness.
Client Knowledge
and Self-Efficacy
Improved
Health Outcomes
Improved
Quality
of Care
Improved
Health
Behaviors
Disease Surveillance
Electronic Medical Records
Remote Monitoring
Logistics monitoring and tracking
Decision Support Systems
Point-of-care Diagnostics
Appointment Scheduling
Client reporting of quality / performance
On-Demand Training / Assessment
Client Education
On-demand Information / Helplines
Supply Chain Integrity
Accuracy of Information
Continuity of Care
Affordability of Care
Financing (Banking, Insurance)
Enhanced Counseling
Improved
Efficiency /
Coverage
Vital Statistics Reporting
Improved
Population
Health
Real-time Data Access / PHRCLIENTPROVIDERHEALTHSYSTEM
Remote Consultation
Improved Dem. / Hlth. Data
Appropriate Resource Alloc.
Policy Adjustments
Workflow Management Systems
Responsive
Health System

87. Is your “mHealth” the same as
my “mHealth” ?

89. Why a mHealth and ICT
Framework for RMNCH?
•Allows focus on health systems strategy of the
mHealth innovation, not just the technology.
•Provides projects with a communication tool when
talking with different stakeholders, including
governments about what mHealth offers.
•Allows identification of uniqueness, commonalities
and gaps across multiple mHealth projects through
the use of a consistent and health systems-focused
vocabulary.

90. 12 Common mHealth Applications

91. RMNCH Continuum:
Known Interventions
mHealth Strategy: …overcoming
these constraints:
Touching these
“actors” in the
system:
Labrique, Mehl, Vasudevan et al. 2013 (MS in Review)

92. Labrique, Mehl, Vasudevan et al. 2013 (MS in Review)

93. Step 2: Develop repositories of
m-evidence and m-activities
Help to identify, collate and grade the
quality of information on mHealth
strategies

94. What do we know ? What has been tried ?
mHealthEvidence.org / mHealthKnowledge.org

95. Helping to Consolidate efforts Globally
And other partners…
MREGISTRY.ORG
A Global mHealth Project Registry

96. Step 3: Facilitate the review and
synthesis of evidence
Help to understand when sufficient
information exists to recommend
mHealth as part of the standard of care

97. What kind of evidence ?

101. mTERG Criteria for Grading mHealth
Information Quality

102. Step 4: Create tools to help with
structured evaluation, common
indicators moving forward

103. Develop Common Indicators and
Measurement Standards for
mHealth Projects
Agarwal et al. mHS 2013

104. Evidence Prioritization Summary
mHealth strategies likely to demonstrate:
• improved client access to information
• enhanced traditional methods of counseling and BCC
• bolstered client adherence to medication, and attendance to
scheduled appointments
• shortened turnaround time for performance data submission
• improved workforce scheduling, monitoring and accountability
• improved workforce training and continued education
• supported caregivers through decision support tools
• strengthened commodities supply chains and reduce risk of
stockouts
• created shorter feedback loops for systemic response
“mHealth Extends REACH, Creates CONVENIENCE, Shortens INFORMATION lag,
and Facilitates TARGETTED CARE when and where its needed.”
mTERG

105. Where can we have the most impact ?
Mehl G, Labrique AB. Science Sept. 2014.

106. An Ecosystem of mTools for
Cross-Sectoral Development exists!
“m” – spans Health, Agriculture, Education,
Politics, Finance, Data Collection

107. Eras of mHealth
I
Innovation and Experimentation
II
Discordant Proliferation
III
Scrutiny and Consolidation
IV
Integration and Scale

109. Degree to which the mHealth strategy changes the status quo
INCREMENTAL CHANGE DISRUPTIVE INNOVATION
DIFFICULTYOFSCALING
COMPLEXITYOFENGAGEDECOSYSTEM
INSTITUTIONAL/HEALTHSYSTEMINERTIA

110. Challenges
- Tentative funding for pilots and
demonstrations, limited investment in
scale
- Rapidly growing, complex ecosystem
with new non-health actors
- Duplicative efforts, lack of
interoperability
- Siloes of innovation, without clear
pathways to integration
- Economic evaluations of mHealth
interventions are lacking

111. • For scale-up / Mainstreaming of mHealth, we need to:
• …Reach BEYOND the “converted”
Speak the language of HEALTH decision-makers
• …STOP taking shortcuts – measuring attributable
impact or cost is not an afterthought, an inexpensive
or easy task.
• …SUPPORT a high threshold of information quality,
establishing new methods where appropriate, but
aligning claims with data.

112. Two last thoughts

113. A phone… as a phone !

114. From this…

115. To this ?
More data is
not better
information.

116. Draw inspiration from Botswana and Bangladesh to Brussels and Baltimore to
understand what is m…… POSSIBLE
Thank you.
http://tinyurl.com/mpossible-video

117. Mobiles ?
alabriqu@jhsph.edu / @gmail.com
alabriqu jhumhealth
www.jhumhealth.org

119. Follow a robust process
USERS
•Identify Users
•Define Target Population
ROLES
•Define Roles
•Map Workflow / Scheduling rules
DATA
•Map Data “Universe”
•Deconstruct data elements
OPTIMIZE
•Assess Data Efficiency
•Identify opportunities for Optimization
DESIGN
•End User Engagement
•User-Acceptability / Functionality
BUILD
•Program, Deploy, Test
•Evaluate

120. UN IWG mHealth Catalytic Grantee Projects
mehlg@who.int

127. Other Tools: Balsamiq.com

128. Other Tools: Captricity