Busting the paradigm about mobile for health: it’s not just phones and browsers. (Morgan Stanley, April 2010)

Previous title: “Morgan Stanley, April 2010: Mobile will be bigger than desktop. Discuss, re health.”

Thanks to @Rohal and others for tweeting about a talk on internet* trends Tuesday by Mary Meeker of investment banker Morgan Stanley, at their Future of Media conference. Those slides are here (PDF), but @Rohal steered me to an April slide deck that has more relevance to me. I’m not sure what to make of all this, so let’s discuss.

* I’ve adopted Pew Research’s house style – lowercase for the word internet. They feel it’s become a common noun.

Mary, if you’re out there, I’d welcome your thoughts. I’m well aware I don’t know your turf.

Our colleague Susannah Fox of the Pew Internet & American Life Project has done much research about trends in mobile, particularly about health. In contrast, Meeker focuses on overall big trends. She sees aspects I’ve never noticed, like what-all constitutes mobile: when I hear the term, I think handheld phones (iPhone, Droid, Blackberry), but she makes the case that mobile web access (and other wireless) is much more than phones.

As we think about how mobile can transform what’s possible in healthcare – especially access to health info and services for people globally who don’t have home PCs – this is important. Flip through the slides; my starter questions are below.

#7, Mobile internet ramping faster than desktop did: the chart overlays quarterly growth curves from the start of different technologies: iPhone/iTouch vs Netscape (browsers) and AOL. Cautiously I note that huge number of *phone* sales doesn’t necessarily equate to internet *use* – but, there’s no question they all do bring mobile internet access.

#12 -Social Media usage surpassing email usage: Fascinating pair of curves – the number of users of email isn’t far behind, but usage of socmed zoomed past three years ago. Question: how much of your inbox is stuff you want to keep, vs the more “champagne bubble” nature of social media – view / pop / gone?

Relevance for health thinkers: if we want to reach people we better be where they are. (See e-patient white paper, chapter 2, Seven Preliminary Conclusions.)

#13, Cloud Computing applications: Notice that just about everything is there, except our health data.  I bet that’s going to change, and a key driver may be parents wanting handy access to their kids’ medical info – the Mama Lion effect we’ve discussed here.

#17, Ten Year Tech Cycles - I’d note that the later decades are off by 5 years: PC/Mac started mid-decade (1984), browsers ’94, mobile browsing mid-2000′s. But the point stands.

#18, Reduced Usage Friction: This is the one that made me decide to write here. More power, better usability, more apps, more services => 10x more devices. True: I myself have just switched from a Blackberry to a Droid X. Why? On an 11 day speaking tour with my wife, time after time we got out her Droid because it could solve a problem that my BBY couldn’t.

That’s important: on the road we were more like people with no home broadband.

The Droid’s not an easy transition for me – it’s such a gadget that it’s not always obvious how  to answer the phone app when it rings. (For me to say that is going some.) BUT, as Meeker’s later slides show, what I now have in my hand is very different from a mere phone and email appliance.

But on the right side of the slide, look what Meeker includes in mobile:

  • iPad (which is not a phone)
  • Kindle (can access data (books, newspapers) but it’s not a Web browser)
  • MP3 players (at least the ones that can download media)
  • Car electronics – e.g. GPS that can access traffic data, gas prices etc)
  • Home entertainment (is Netflix mobile if it’s tethered to your Wii or cable??)

Combined with earlier slides on mobile’s market share, this made me remember: “internet” is not just web browsing. I knew that – my ACOR.org cancer patient listserv is internet but not Web – but it somehow had escaped my thinking about the future of mobile for health. Any mobile device that can get at data over the internet is mobile internet. Duh.

#19: Good summary of the evolution of how we use devices and what we use them for.

#31: Well executed infographic on the shift in how people spend time online. Facebook and YouTube rising, all others shrinking. But where do non-Web apps (see above) fit into this?

#35: Salesforce.com cloud enterprise computing platform. READ THIS and understand it.

  • This is the sales & marketing management system that I managed at my last day job. I know this system. It’s usable, very powerful, and very very extendable with plug-ins and apps. (Not perfect, not easy, but usable and powerful.)
  • For a long time, big-iron system vendors like Oracle and Siebel poo-pooed Salesforce as not powerful enough for real companies. Within ten years it kicked their butt; in 2008 Cisco Systems bought a worldwide site license, pretty much ending any question about whether it’s powerful enough for “real companies.”
    • That is a classic example of Clayton Christensen’s “disruptive innovation” concept.
  • I’d bet my house that the same thing is going to play out in EMR / EHR systems. Watch. It may take ten years again, but watch.
  • btw, Salesforce.com is a major investor in disruptive EMR/PHR vendor PracticeFusion. Watch.

#37ff – VoIP (voice over internet, e.g. Skype): just notice that the whole idea of what a “phone” is has come apart at the seams. There’s the thing that hears your voice (might be in your desk phone, your handheld, or desktop computer’s mic), the thing that emits the other person’s voice (same list), and the part that carries the sound might be heaven-only-knows-what. Cable modem, wifi, cell network, who knows.

And be aware that the same applies to video. As quality gets better, what does this mean about the concept of a doctor “visit”? How does the world change if your nurse can see you without you leaving home or office and waiting in her waiting room?

This doesn’t replace all office visits but it can replace some. As American Well has proven, it’s a tier of care, which people love – they’re growing like a weed. And yes, insurance pays for it.

#43: Mobile Web and app usage far outpaces share of devices sold. This bolsters the point that these devices in no way resemble a Blackberry (the “RIM” column). And that awakens me to the reality that an app phone is a completely different device.

Is it appropriate for us to talk about smartphones anymore? Seems to be the split is between app phones and non-app devices. This chart makes clear which is which.

#44: Changes in device share – another lovely infographic. RIM (Blackberry) is being crushed by app phones. (Note – this goes through Feb 2010; Android has grown more, and the new Windows Phone may change the mix.)

#54: ShopSavvy app – a spectacular example of mashups of data from different sources.

  • Imagine this kind of shopping power applied to finding treatment options. (Yes, this is blue sky, not around the corner. Imagine it. For your kid, your elders, your friends.)
  • Imagine the mashup possibilities when combined with the government’s Open Health Data initiative.

#63: Note that health is not yet on the radar.

#75 – Payment issues on desktop vs mobile - very important to the business future of these apps, and thus the investment future. Especially the first bullet: mobile has easy-to-use secure instant payment; desktop browsers don’t, and are open to widespread fraud. (My own experience taking payments by PayPal has taught me how big an issue this is – PayPal can get hobbled by its own security against hackers. This is a big impediment to growth.)

_________

All in all this post popped my mind open to a new awareness of what mobile connectedness is – it’s not just phones with better browsers. Yeah, I know a lot of you knew that, especially iPhone users. Don’t yell at me; I give you credit for being quicker. :)

I didn’t take time to comment on everything; as it is, this took three hours. What do you see about the future of health, in light of all this?

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Comments

13 Responses to “Busting the paradigm about mobile for health: it’s not just phones and browsers. (Morgan Stanley, April 2010)”

  1. AuraViva says:

    AuraViva also commends Mary Meeker on developing a fantastic slide deck and getting arms around the overall Internet trends. We wanted to extend comment to e-Patient Dave on #13 point in that we might be closer than we think, given there are cloud platforms for medical devices in the market today (isidorey.com/medical) that can securely transmit data from biosensors and medical devices. Now, perhaps patients can have a virtual appointment with a nurse and ‘bring’ objective clinical data to the appointment too! We are a big fan of Susannah Fox of the Pew Internet & American Life Project, as well, so a big shout out to e-Patient Dave, Mary Meeker for furthering the conversation. Sincerely and in 24 hour wellness, AuraViva.

    • Susannah Fox says:

      Thanks for the shout-outs! I need to spend some time with this analysis before I comment about it specifically, but let me provide some links to Pew Internet’s research:

      Mobile (all reports, presentations, commentaries)
      http://www.pewinternet.org/topics/Mobile.aspx

      Highlights:

      - My former colleague John Horrigan (currently at the FCC) noted the disruptive potential of mobile/wireless back in 2003. Anything I said in those early years about mobile was coat-tailing on his analysis.

      - I started beating the mobile health drum in earnest in 2008 with my Seven-Word Wisdom speech at Health 2.0 San Diego: http://e-patients.net/archives/2008/03/recruit-doctors-let-e-patients-lead-go-mobile.html

      - My current “what mobile means for health” is captured by this speech: http://www.pewinternet.org/Commentary/2010/September/The-Power-of-Mobile.aspx

      - And here’s the (very short) mobile health report I recently wrote: http://www.pewinternet.org/Reports/2010/Mobile-Health-2010.aspx

      • Yes, I recommend the 15:47 video Susannah linked to http://www.pewinternet.org/Commentary/2010/September/The-Power-of-Mobile.aspx of her talk at Mayo Transform this fall, about the “sea changes” we’ve seen in mobile, broadband and internet access in general. If you don’t want the video, the transcript & slides are there too.

        Some juicy quotes:

          ♦ ”Ten years later, I am ready to declare the access revolution over, at least in the United States. It’s time to change our frame of reference. Instead of talking about a revolution, our data shows that it is time to start building a new civilization.”

          ♦ ”A mobile device is the internet for many people. Access isn’t the point anymore. It’s what people are doing with the access that matters.”

          ♦ ”Mobile + broadband adds up to much more than 1+1. Each one has a multiplying effect on people’s behavior.”

        “In 10 years we have seen the internet go from a slow, stationary, information vending machine to a fast, mobile, communications appliance that fits in your pocket. Information has become portable, personalized, and participatory.” Emphasis is hers

          ♦ ”We’ve identified an effect that we’re calling “the mobile difference.” Once someone has a wireless device, they are more likely to use the internet to gather information, share what they find, and create new content.Emphasis added

          ♦ ”If your organization’s information is not available on a small screen, it’s not available at all to people who rely on their mobile phones for access. That’s likely to be young people, people with lower household incomes, and recent immigrants – arguably important target audiences for public health messages.”
        ____

        As we think about the future of patient engagement, all these are important, because it seems that our whole paradigm of what engagement is is subject to change.

        When I first heard Susannah’s talk I was thinking about simple phones. It all feels different in light of the pile of devices Mary Meeker describes – and the applications and payment tools they carry.

  2. Rob Halkes says:

    Great analysis on a great set of data and overviews, Dave. I’m very impressed by the speed and thoroughness of your analysis going through all the data.

    And indeed, just as you was, I was struck too, to acknowledge that we have become to think that mobile is about phones, but it really is about mobile accessibility to the net! Makes indeed a difference.

    Now as you are wondering about the difference in the use of “mobile” in other business than care and the uses in care, there are the specific characteristics of caring for health that do not exist in other branches of business. To give a specific example: patients’ uncertainty about how to deal with the (authority) of the doctor/specialist, or the separation between client roles like who is indicating the need, who influences the choices of services and who is to pay, and other peculiarities, all make up the specificity of the business of care.
    As long as health care is characterised by these peculiarities, it will be difficult to compare it with other business. In interpreting data and in designing improvements and innovation in caring for health, we should be aware of that.

    From this perspective, I think that the thing about devices, the net and apps, is the intention with which it is conceived, designed and applied to care:
    Is it about “Djee we ‘ll just apply some technological device so as to … etc.” Or, on the other hand: we do want to improve caring for health and thus we should rethink the actions/interventions/relations/communications etc… so, let’s see what the availability of this new technology could offer us: how could we redefine and redesign care and then move on to make the technology work effectively, and not just as an “add on” to ways of care that have flaws to begin with..

    Although I will not deny that certain add on aspects are nice and also give extras, I’m convinced that given the means, we should rethink and redesign the fundamentals of care. It will surely give a better application to “mobile” so as to be able to generate improved outcome of health care on less costs.

    Thanks
    Rob

  3. Dave and Rob,
    I credit you both for helping me get over an inexplicable reluctance to participating in m-health discussions. (Well maybe not so inexplicable — there’s just so much to keep up with.)

    First your tweets intrigued me and then this post fleshed things out. Now that I’ve grasped that m-health is more than just phones and I recognize the powerful potential that everyone else has been going on about. Thanks for getting me up to speed or at least able to get more informed.
    Colleen

    • it’s an honor to be a help to you, great one! Thanks for the feedback.

      • Dave,
        I seriously just looked over my shoulder to see who you were referring to! “Great one”?? ahem, you forgot the winking emoticon right? Watch it or my head will bust my avatar.
        Thanks.

        • Seriously, you are clear-headed, compassionate, empowered, proactive, kind, and generous. I assert that it would be a great world indeed if most people were like you.

          And I recommend you share the same sort of feedback with others you meet who strike you that way. It’s fun, and … empowering. :–)

    • btw, Colleen, I’d caution against thinking of “mHealth” is anything specific or anything valuable … A shorthand term like that is catchy but I suspect in this case it can be deceptive.

      15 months ago when I was considering what line of work to choose in healthcare, I noticed that the industry lacked an observer who was both tech-savvy and business-savvy. It would have been a steep hill for me to climb, but I remembered many years ago The Seybold Report on Typesetting Systems, which had just that sort of savvy, and I knew this business needs one.

      Some months later I ran into John Moore of Chilmark Research. When I read his then-new blog, my gut said that issue was solved. I stopped thinking about being that, and started following him instead.

      And his impression is that a whole lot of people are smoking the wacky weed about “mhealth” – that it’s a cute concept but not anything specific. His post Wednesday, after attending the mHealth Summit, says “mHealth is unlikely to ever become a market in its own right.”

      He continues:

      The question is not whether or not there is an mHealth market, the question is: How will mobile technologies and devices change care delivery models? … [Also note] as I have said many times before, health does not occur when you are sitting in front of a computer, it is mobile, it is with you, it is you.

      Reread the slide notes with that quote in mind. I suspect he’s right when he says we’ve been thinking about the whole subject from the wrong angle; I suspect some unpredictably new things will emerge at some point, perhaps unexpectedly, springing from the fact that we have these gadgets with us all the time.

      For me it starts with becoming conscious of what the gadgets are. That’s why this gripped my attention. I’ve been thinking wrong.

      • The quote you pulled from John Moore’s blog is the sentiment that has helped re-frame my thinking about mobile health. It was also the over-riding conclusion in the #hcsmeu conversation last Friday. Health care, regardless of the tools, is about people. People choose the tools that enable them to reach their goals/needs.

        • Catching up a bit later:

          Colleen, the view you and John Moore cite (“health is you, it’s with you, it’s about you”) brings us full circle back to Doc Tom Ferguson’s magazine, Medical Self Care. A quote from an interview of Tom:

          Clearly, the medical establishment has become a threat to the average American’s budget (if not his health).

          Which is one reason why medical self-care—the idea that health care should, to some degree, be taken out of the hands of physicians and put back into the hands of consumers—has started to become so popular in this country over the past few years…

          That was in 1978. Check our post a few months ago for that interview and more.

          “Into the hands of consumers” indeed: mobile gives it a new meaning…

  4. Dave,

    I’m glad you wrote this post, both for highlighting the Meeker preso on Internet Trends and even moreso for the qualifier “it’s not just phones and browsers”. A fair amount of the push back about the potential of mHealth (and even the term itself) that I heard at the mHealth Summit and prior can be attributed to a flawed understanding of what mHealth means. I am partial to the mHealth Aliance’s take: mHealth is the use of mobile devices and global networks to deliver health services and information. Note the use of ‘devices’ rather than ‘phones’ and the inclusion of ‘global networks’, which is just as crucial.

    Every semester I give a lecture on mHealth in the colleges of medicine & pharmacy and I recently posted a summarized version (http://slidesha.re/956kPg). My (obviously biased) opinion is that it also serves as a Q&D primer as it includes the Alliance definition, goes through examples of the mHealth Initiative’s 12 Clusters, and helps illustrate why ‘mobile penetration’ is one of the most misquoted and understood terms. The slides also touch on less intuitive types of mHealth such as wireless assisted living & ‘nana technology’ (recently mentioned by @SusannahFox), wearable cardiac monitoring systems, SMS-mediated patient recruitment & retention for clinical trials, public health applications like Frontline SMS Medic, etc.

    Kevin

    • Wow, Kevin, my hat’s off to you as a PowerPoint jock. Terrific layouts and images.

      Oh, and your content’s hot, too. :) Well done!

      Re “devices” – until this discussion, I’d only heard people say devices as (apparently) overly cool name for phones. Not so much, now.

      I’m glad I went ahead and wrote the post, knowing full well that I didn’t know *enough*. I learned a lot, as a result.

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