An interview last month with Rick Valencia, VP and GM of Qualcomm Life, at U-T San Diego offers insights about why some big names are investing in wireless health—and why success has so far been elusive.

Valencia sees wireless health serving different purposes in different settings. In developing countries, it provides access to care in remote and rural areas. In developed countries, wireless health has the potential to reduce the cost of care by helping people stay well and providing services outside of expensive “acute care settings” (hospitals and emergency rooms).

Honeywell HomMed has made a similar point. Remote monitoring can be used to avoid hospitalizations by detecting problems before they become acute and to shorten hospital stays by allowing patients to be released earlier (to be closely followed at home).

Qualcomm’s 2net Hub and new 2net Mobile devices suggest that the industry still needs help connecting mobile and remote devices to the network and managing them.

Valencia’s last comment was interesting but enigmatic. He said that under new health care laws we are moving away from fee-for-service to a “capitated” environment. In the past, when a patient showed up it was a revenue opportunity. In the new system, when a patient shows up it will be viewed as a cost. Valencia believes this will motivate physicians and hospitals to reduce costs. “They can make a choice to pay for something and not get reimbursed at all if they know that by paying for that, it is going to bring down the total cost of care.”

Valencia is right in that consumers will do everything they can to avoid expensive acute care settings. But I don’t see how a “capitated” (top-down) environment will lead to lower costs. It may seem counterintuitive to many people, but experience shows that (regardless of intentions) top-down systems end up being wasteful and expensive. Competition is the only force that drives down prices to the marginal cost.


UPDATE (December 17, 2013): Eureka! (Or perhaps I should say "Duh!"). When Valencia refers to a "capitated" system he means one in which doctors are paid by the head rather than for specific services rendered. Yes, this will certainly motivate doctors and hospitals to reduce costs. (Though they can do that simply by withholding services.) I have just started reading Your Doctor Is Not In by Jane Orient which presents a glossary at the beginning and defines "capitation" as a feature of some national/socialist/managed health care systems.

Armed with this more specific definition, I think Valencia is way too optimistic if not flat out wrong. In a capitated system, doctors will spend as little of their own money as possible. They are unlikely to invest in infrastructure just because they believe it might reduce costs. Instead, they may lobby bureaucrats to implement wireless health by decree. In the absence of market forces (and the corrective feedback that entails), wireless health will become just another government boondoggle.

Many people believe that extending the Internet to things is a major opportunity. A “thing” could be a window, an automobile tire, or (for our purposes) a person’s arm. However, it does not make sense to literally connect a person’s arm to the Internet. We are really talking about connecting a sensor or controller of some sort to the Internet.

The Internet of things calls for a networking technology that is flexible, easy to deploy, and easy to use. It should be able to relay sensor data and controller commands in a timely, reliable, and (when necessary) secure fashion. And it should enable devices that are small, inexpensive, and consume minimal power. Ideally, it should be wireless, support ad hoc and mesh networking, and enable devices that can run for years off a small battery. ZigBee, a solution ten years in the making, meets these requirements.

There are two major potential health applications for ZigBee. One is connecting personal health devices to PCs and smartphones. Another is providing coverage throughout a home or care facility for patients who need continuous monitoring and emergency signaling.

While ZigBee would be an excellent solution for personal health and fitness devices that require long battery life, it faces stiff competition from Bluetooth low energy (BLE). Bluetooth is already widely used by mobile phones, tablets, and PC peripherals. And BLE-equipped personal health devices are starting to hit the market. However, markets often evolve in unexpected ways, and ZigBee may yet find its way into consumer health and fitness devices. As Cees Links, Founder and CEO of GreenPeak Technologies points out, ZigBee can do things that Bluetooth can’t.

A case in point: using ZigBee to continuously monitor elderly and chronically ill patients in their homes or assisted-living facilities. In these situations both low power consumption and building-wide coverage are essential. ZigBee enables building-wide coverage using its mesh networking capability. For example, a patient in an assisted-living facility could be continuously monitored in both their apartment and common areas.

Keep in mind that home monitoring can help patients avoid expensive hospital stays (through early detection) and reduce the length of stays (through early release). Honeywell HomMed has been able to sell more than 70,000 home health monitors with intermittent monitoring (wired and Bluetooth). Imagine how much more effective these devices would be if they provided continuous monitoring via a wireless technology such as ZigBee.

AliveCor announced today that its Heart Monitor iPhone ECG for the iPhone 4 and iPhone 4S has received FDA clearance for sale and is ready for preorder. The add-on device sells for $199, is "for use by licensed U.S. medical professionals," and will begin shipping in early January 2013.

The FDA approval process raises a few issues. Could "licensed U.S. medical professionals" prescribe the device for use by patients? Presumably, one advantage of the device is that it would enable patients to be trained to capture and transmit single-channel electrocardiograms to their physicians. Given how rapidly new smartphone models are introduced, is there an accelerated approval path for other versions of the device? And while it makes sense for the FDA to certify that the device does what it claims, it's not clear that that justifies delaying its introduction and restricting sales. Who is to say that a PhD in Biology is not qualified to use this device?

Regulatory issues aside, there is tremendous interest in this device and it represents just the tip of the iceberg for new and powerful mobile health technology.

Near field communications (NFC) – featured in recent Samsung television commercials – is the technology that lets users exchange playlists and videos by simply tapping their phones together.

Still, you might wonder whether there is a role for NFC in personal health. There is. NFC is a versatile technology and, as the Samsung commercials demonstrate, its “tap and go” operation can simplify many tasks.

As I explained in my article for NewsFactor Network, “NFC is as close to a cable connection as you can get with wireless.” Though NFC operates at radio frequencies it actually uses magnetic induction. In fact, the NFC antenna is designed to suppress radio waves – not launch them into space. That’s why NFC’s range is only 4 – 20 centimeters. And it’s also why NFC is nearly invulnerable to security attacks from more than a few feet away.

So what are some of the personal health applications for NFC?

NFC is a candidate for connecting consumer devices used to track fitness, monitor vital signs, and perform specialized tests to PCs and smartphones. Today, these devices typically communicate via a USB cable or Bluetooth. However, NFC may prove to be the better solution because it is easy to use and works with passive wireless sensors (such as the disposable wireless diagnostic skin patches made by Gentag).

NFC is already being used to automate home health care. Visiting caregivers can check in and check out merely by tapping an NFC card worn by the patient or installed in a convenient location in the patient’s home. Caregivers can also use the NFC card to verify the patient’s identity and access the patient’s records.

There is even an NFC solution designed to enable surgical patients to return home sooner. Disposable diagnostic skin patches can be used to monitor variations in pressure and temperature for signs of swelling. The patient uses an NFC phone to collect data from the patches and uploads it to their physician.

NFC-readable biometric sensors could, in fact, revolutionize health care. Sensors can be placed on the body to measure things such as blood pressure, heart rate, body temperature, blood oxygen, blood glucose, cholesterol, and prothrombin time. Self-test kits for pregnancy, AIDS, and even certain types of cancer can provide NFC-readable results.

NFC can be used to assist visually impaired and physically disabled shoppers. Product displays are equipped with NFC tags that provide product details such as pricing and ingredients. An NFC phone or tablet reads the information aloud using synthesized voice. Visually impaired patients can also use NFC to identify food and other packaged goods at home. NFC can even be used to create “talking medicine packages.” The patient taps the package with an NFC phone for spoken information and directions.

NFC is being applied to monitoring potential sleep disorders. A small card is attached to the patient’s arm and is used to monitor the patient’s physical activity overnight. The card can be read by an NFC phone in the morning and the data can be sent to a physician or therapist.

At least one company (Poken) is using NFC as a substitute for business cards and brochures, and health care is one of their primary target markets. Consumers attending health workshops at local hospitals can collect information with two-way tags (called “Pokens”) and continue interacting after the event via an online hub.

NFC tags can also be used by patients or caregivers to call emergency services. The user taps the phone on a passive tag and the call is automatically placed. The patient’s name and address may also be uploaded.

NFC has a couple of weaknesses. Though NFC is not a good solution for exchanging large quantities of data, it can be used to set up a secure Bluetooth connection. And though NFC’s physical link is extraordinarily secure, NFC phones are vulnerable to rogue tags placed in public locations by mischief makers.

If NFC becomes relatively ubiquitous – as it seems poised to do – then people will surely invent many other personal health, fitness, and safety applications.

This is the first in a series of posts about the wireless options for personal health technology.
Newcomers are often confounded by the number and variety of wireless choices. There’s no single technology that is best for all applications. Wireless is evolving so rapidly that products following the latest standards are usually backward-compatible with older standards. To further complicate things, there are different standards and frequency allocations in different parts of the world.

Even for a well-defined application, the choice is often not simple. Consider the female patient with a life-threatening heart condition who needs to be monitored continuously. The most important factor in this application is coverage, so she needs a device that uses the cellular standards that blanket the area in which she lives, works, and commutes. Coverage may be spotty indoors, so the device should also support Wi-Fi. And it should employ one or more radio-locating techniques to ensure that paramedics will know where to find her in an emergency.

Here’s a brief overview of wireless technologies for personal health applications. I’ll delve deeper into specific technologies in future posts.

Cellular: Operators are currently deploying fourth generation (4G) technology for Web browsing and multimedia, but the more ubiquitous 3G technology is fine for most health apps. Given that operators are moving away from unlimited data plans, it’s best to use free Wi-Fi where available (homes, offices, and many Wi-Fi hotspots). If you travel internationally, a GSM model may be your best choice. Smartphones are preferred over basic mobile phones as they can run health and fitness apps. There are even smartphones optimized for health needs.

Wi-Fi: Wi-Fi was developed to replace indoor cabling, but it’s also used to create indoor hotspots and outdoor hot zones, and support for device-to-device transactions has been added. Withings, a French company, offers weight scales that can communicate via either Wi-Fi or Bluetooth; Wi-Fi makes most sense when the scale is permanently stationed in a bathroom because it offers longer range than Bluetooth.

Bluetooth: Bluetooth was developed for personal area networks—it’s best known for wireless headsets and hands-free operation in cars—but it’s also a good choice for connecting personal health gadgets to PCs and other devices. A relatively new Bluetooth mode, Bluetooth low energy (BLE), enables devices with long battery life. A heart rate monitor with BLE can periodically upload data to a smartphone for a year or longer using the same coin cell battery.

ZigBee: ZigBee is designed for low-cost, low-power sensor and control networks. ZigBee can be used to monitor the elderly and chronically ill in their homes or care facilities. It’s also a good fit for a range of personal health and fitness applications. Philips Hue, a ZigBee-controlled LED lighting system, offers light therapy for the winter blues (otherwise known as seasonal affective disorder, SAD). The lights’ brightness and color can be controlled with an Android or iOS device communicating via Wi-Fi to a controller that, in turn, communicates with the LED lights via ZigBee.

Near field communications (NFC): Thanks to its very short range (4 – 20 centimeters), NFC is most often discussed as a secure connectivity solution for mobile payments. However, NFC can also be used in health care facilities to track patients, drugs, and any other items with programmable tags. NFC can also be used by individuals to collect data from wearable sensors and to track prescription drug use.

Satellite: Satellite communications may not be practical for most health and fitness apps, but it is uniquely qualified for search and rescue operations. There are messaging devices for adventurers that can be used to signal for help. Some will even call for help automatically under specific circumstances. Satellites are also used along with cellular to guide emergency services to the site of a major automobile accident.

Radio-locating: Bystanders can use locating technology to find the nearest emergency room or public external defibrillator. There are two global satellite navigation systems, one operated by the US (the global positioning system, GPS) and one by Russia (GLONASS). Unfortunately, satellites have trouble covering indoor locations, urban canyons (areas between tall buildings), and tree-lined streets in the summer. Users can also be located based on their distance from cell towers or proximity to Wi-Fi networks.

Next I’ll take a closer look at NFC and ZigBee, two relatively new technologies with unique advantages.

comScore reports that the number of mobile users accessing health information from mobile devices more than doubled over the past year. During the 3 month period from Sep 2011 to Nov 2011, there were 16.9 million mobile health information users. comScore also reports that 60% of the users were under age 35. Unfortunately, the post doesn't say anything about the type of information accessed.

The U.S. Food and Drug Administration (FDA) is hoping to extend its regulatory fiefdom to mobile medical applications. The agency released its draft guidelines on July 19, 2011 and will accept comments until October 19th.

The FDA portrays the guidelines as uncontroversial. "These are the devices we have been regulating all along and just because they are on a mobile platform doesn’t mean we should be regulating differently,” the FDA's Dr. Jeffrey Shuren told MobiHealthNews. It's telling that the FDA doesn't cite examples of anyone being harmed.

However, the FDA’s argument that it is merely being consistent can also be used against the proposed guidelines. As the same article in MobiHealthNews pointed out, in 1989 the FDA proposed guidelines for regulating PC-based products but was forced to abandon the effort when the number and variety of such products quickly mushroomed.

The FDA also downplays the guidelines’ significance by pointing out that only a small percentage of mobile health apps would be affected. To wit, the guidelines only apply to apps that are used to diagnose and treat medical conditions. These include mobile apps that work with already regulated medical devices, mobile apps that turn handhelds into medical devices, and mobile apps that issue recommendations about a patient’s diagnosis or treatment.

The FDA's Bakul Patel commented, "We are starting off with the very small tip of the pyramid"—implying that we should be grateful that fitness and wellness applications are not included. He offered the hypothetical example of an app that transforms an iPhone into a stethoscope. Since stethoscopes are regulated, apps that turn iPhones into stethoscopes should also be regulated.

I challenge the wisdom of regulating stethoscopes in the first place. If physicians aren’t smart enough to purchase decent quality stethoscopes, then they probably aren’t smart enough to use them properly. Besides, I see no evidence that the FDA is smarter than most physicians, and the risks associated with regulating stethoscopes are arguably as great as the risks associated with not regulating them.

Patel explained the FDA is focusing on new risks posed by mobile platforms including small screen size, lower contrast ratio, uncontrolled ambient light, and use of the apps by ordinary consumers. However, all products have limitations, and the idea that a government agency can somehow eliminate them creates a dangerous illusion. Besides, these limitations are rather obvious. I would rather that physicians and consumers be mindful of the limitations than be denied affordable and timely products.

Instead of scheming to establish new regulations, the FDA would be wiser to take the opportunity afforded by mobile medical apps to test a completely different approach. The FDA could better serve the public by testing and reviewing mobile medical apps while subscribing to the highest standards of objectivity. This would enable the FDA to earn immense credibility while permitting physicians and consumers to make their own choices. I would hate to see this exciting new industry handcuffed by burdensome regulations.

Smartphones and tablets are booming, and their impact on health and fitness is just beginning to be felt. So which platforms should app developers target?

MyVirtualHealthCheck's announced launch of its Windows 7 version caught my eye. The app was already available for the iPhone and Android, so Windows 7 must have seemed like a natural next step. MyVirtualHealthCheck appears genuinely excited about the added functionality of Windows 7's user interface.

MyVirtualHealthCheck offers a single app for recording and sharing vital signs. It also provides access to a nutritional database and its chronic disease management website. There is even a location-based "Healthy Spots" feature that identifies nearby health food restaurants (among other healthy things).

The iPhone and Android versions are safe bets. I'm not as sure about Windows 7. Microsoft has been chasing the smartphone market for about as long as anyone—and with little success. Apple and Google just marched right in and swept everyone else aside. Microsoft's announced strategic alliance with Nokia is not so much a coup as a swan song. Nokia is the world's leading maker of mobile phones, but everyone knows that they are a has-been.

WellDoc and AT&T mHealth Solutions have begun field testing WellDoc’s DiabetesManager among employees of AT&T and Health Care Services Corporation (HCSC). The FDA “cleared” software tool runs on mobile devices and helps patients with Type 2 diabetes manage their treatment and reduce their health care costs.

DiabetesManager is based on WellDoc’s health platform consisting of three core modules: Expert System, System Support Tools, and Patient Coach. The product reminds the patient when to test their blood glucose, makes meal recommendations, provides medication reminders, and keeps caregivers informed.

In addition to helping patients stay within range (in part, by modifying their behavior) and alerting caregivers about problems, DiabetesManager could provide the longer term benefits of providing patients with more personalized therapies and helping doctors better understand what does and does not work for Type 2 diabetes patients.

MDconnectMe is an app for secure, private communications between doctors, patients, family, and friends. The app enables doctors to send updates to patients and others designated by the patients. Update messages can be delivered to PCs, iPhones, Android mobiles, and other devices.

The problem is obvious: most doctors are very busy and communicating with patients, their families, and their friends is time consuming and often frustrating to everyone involved. In theory, an application such as MDconnectMe should be more efficient for physicians and satisfying for patients and their support networks because it enables asynchronous communications. Put simply, it frees doctors from having to establish real-time communications with diverse parties.

In practice, the success of this app depends on how caregivers use it. Status updates must be prompt, unambiguous, and reasonably frequent. Physicians should use the app to supplement direct contact with the patient and a close relative or friend—not as an excuse for avoiding direct contact. If the app does not let patients assign their designated recipients to different groups, then that capability should be added. A patient may want a dozen people to be informed when things are progressing smoothly. But that same patient may not want all twelve involved when tough decisions need to be made.

MDconnectMe, if used properly, should keep patients and their support networks well informed. But it could also be used to dodge tough questions, sugar coat bad news, and avoid the kind of direct human contact that will always be a necessary part of the physician-patient relationship.

A service is being rolled out that could help save lives. Guardly enables smartphone users to quickly connect with family, friends, and emergency services. For example, if you think you may be experiencing a heart attack you could use Guardly to notify your emergency network and automatically provide your location data. Now available for the Apple iPhone, Guardly reduces the steps required to dial 9-1-1 and sends members of your emergency network a link to an “emergency response page.”

A related application called Fire Department can be used by members of your emergency network to find the nearest automated external defibrillator (AED) or person trained in cardiopulmonary resuscitation (CPR). The American Heart Association estimates that 20,000 lives could be saved using AEDs.