The number of mobile health applications keeps increasing fast. With mHealth being a subset of the broader digital health ecosystem, the landscape of start-ups offering such applications is highly diverse.

In order to succeed mobile health applications, need to be problem-driven, have a proven medical and socio-economic benefit and provide an effortless experience for users. That’s what Valerie Storms says. Valerie is program manager of the Mobile Health Unit (MHU), a center of expertise in mobile healthcare, built on the collaboration between Hasselt University, Jessa Hospital and Hospital East-Limburg. MHU focuses on research and innovation projects in the domain of mobile health applications and collaborates with industry to support development & validation of digital sensor technology.

At the occasion of her presentation at the 5th Conference on Digital Health 2019, she sheds her light on mobile health and shares some of the lessons learned by the MHU where mHealth innovators have found fertile ground. Valerie tackles some of them, with the EC- and FDA-approved FibriCheck application taking center stage. At the event Valerie will talk about ‘Mobile Health technology, from bench to bedside’.

Valerie is the guest for our fourth speaker interview. Previous interviews tackle telemedicine (speaker Leonard Witkamp), the transformation of hospitals with Wouter De Ploey, CEO of ZiekenhuisNetwerk Antwerpen and the digital transformation of healthcare with Frank Dendas from Philips.

The Mobile Health Unit: improving research in Limburg

Can you start by telling us more about the Mobile Health Unit?

The Mobile Health Unit is part of a broader collaboration between three partners in the province of Limburg in Belgium: Hasselt University, Jessa Hospital in the city of Hasselt and Hospital East-Limburg, which is in the city of Genk.

In the province of Limburg, we don’t have an academic hospital and the cooperation between these three partners is a way to improve medical and clinical research in our region. Within that cooperation, MHU focuses on research and development in the domain of mobile health, in close collaboration with the industry and other stakeholders. We also support the development and validation of new digital sensor technologies enabling mHealth applications.

Hasselt University and the regional hospitals already collaborated for the education of medical students since we have a faculty of medicine and life sciences where students can get a bachelor’s degree in medicine or a master’s degree in Biomedical Sciences.

This collaboration was a way to make it easier for our students to find internships without them having to need to travel too far. It enabled several win-win situations, also for the hospitals, for instance to attract talented doctors and staff with an interest in research and to create an overall research and innovation environment while helping the students during their education.

In 2012, this collaboration was formalized into the Limburg Clinical Research Center (LCRC) with a strong emphasis on clinical and medical research. Since 2012, more than 50 PhD projects were initiated.

The benefits and challenges of multidisciplinary care

Multidisciplinary care is one of the topics of the event. What are your views? Do you involve other care providers and stakeholders in MHU?

Sure. We work together with the organizations of general practitioners and one of the questions that came up indeed was about the organization of a multidisciplinary care model.

We really want to stimulate that multidisciplinary approach, even for our medical students, whereby we shifted towards having more focus on also developing soft skills: collaboration, communication and even empathy. For skills like collaboration our faculty works together with other faculties like ‘Rehabilitation Sciences’ or with the high schools where the nurses get trained.

But we also value empathy and communication with patients and that’s why we started a patient embassy at our university, which is a sort of ‘independent’ patient community of engaged patients that are involved in the education of medical doctors by sharing patient expertise and experiences.

We believe that multidisciplinary and patient-centric care requires a shift in mindset, so we start doing it as early as possible within the education of doctors.

While in education that multidisciplinary approach is somewhat easier to put in place, in research it’s a big challenge that often requires a lot of resources.

Most of the time the resources for research are limited, also in smaller start-up companies and that’s why for the research projects we focus on smaller parts of the puzzle. So, answering the question what the Mobile Health Unit does: we try to connect primary physicians with specialists, with nurses, with physiotherapists etc. by digital solutions such as mobile apps and software that improves communication between these different care providers. However, when it comes to a multidisciplinary approach across different disease areas, that’s still a challenge.

We have research projects in many different disease areas like cardiovascular and respiratory diseases, renal disease, high risk pregnancies, orthopedics and solutions for patients with heart rhythm disorders.

I think, however, that it will be important to enable a kind of integration between these different solutions in the future. Nor health care professionals, nor patients are willing to use separate digital tools all with a different look and feel. But even more important, on the data level, integration is key to create much more opportunities and impact (precision medicine, predictive medicine, biomarkers,…).

Yet, that requires the involvement of larger companies with more resources and of the government to stimulate that these solutions which are now developed by smaller tech companies can easily interact with those of larger software providers such as providers of clinical record software for hospitals.

Today that is a challenge in getting a large-scale use of the applications that we develop with smaller companies and the research complex.

Clinical record software and the ability to fully leverage data

For many interviewees clinical record software remains an issue. Is this the case in mobile health and your network too?

At Jessa Hospital and Hospital East-Limburg the integration of hospital-wide electronic patient record systems is still ongoing too.

At Hospital East-Limburg a hospital wide EMR system from ChipSoft was implemented last year and there are still many challenges to structure the data in an optimal way to facilitate a broader use than only clinical follow-up. For example, using medical data for artificial intelligence and machine learning applications to really exploit the richness of the information in those electronic records.

For Jessa Hospital it’s still an ongoing project: this year, they will make the transition to a new EMR system, KWS, developed by UZ Leuven. So, this means that you already have two local hospitals working with two different EMR software providers. You can imagine that for us, even if there are of course some groups of hospitals using the same system, that doesn’t make things easier.

Moreover, we often get feedback from industry players that for them it’s too expensive and time consuming to integrate their applications with the EMR of the hospital. Also, for the hospitals it is not always their priority. So, to evaluate the use of new digital care pathways, we work for the moment with standalone software next to the EMR system since we can’t always afford this investment. On the other hand, we still need to investigate the added value of these new digital supported care pathways, making an integration in an established clinical work flow not so straightforward.

Finally, the EMR software in hospitals often doesn’t enable to communicate with these standalone applications of new players as it often lacks the standardization to do so. The new, smaller industry players are ready but the hospitals don’t seem to be ready to work in this standardized way so there is a lot of work to be done I feel indeed.

mHealth works and research proves it

Sooner or later solutions nevertheless will need to be integrated. Yet, the government will perhaps say the system is already too expensive?

The government often looks at the short-term revenues when they invest, and of course, investing in new technology and prevention generates savings on the long term.

We need to convince governments to provide the right financial incentives and enable a framework where it is possible to exploit the benefits of new care models supported by digital technology, e.g. telemonitoring, telerehabilitation or digital diagnostics.

Since I believe we will shift from a supply-driven to a demand-driven reality where patients will ask for a more convenient way of healthcare that takes place in their own environment. I agree with Leonard Witkamp that we will shift towards a system that is closer to the patients’ environment instead of being too focused on hospital buildings. And all these new digital technologies like mobile health and telemonitoring are needed to support safe and accurate care outside the hospital.

For me, it’s just a matter of time before it happens, and I think that healthcare insurers and governments know that it’s the way forward but it’s an evolution and it takes time.

The evidence clearly shows that mhealth supported interventions can reduce hospitalizations or shift hospitalizations to the home situation and that these new approaches such as home hospitalization and telemonitoring enable to realize many savings in the future while meeting the changing demands of patients.

mHealth in Belgium: benefits and a case

What’s the main benefit of mHealth in our region?

In our region the main advantage of technologies such as telemonitoring and mobile health is a more continuous view on the patient.

For people who have a chronic heart disease, or a respiratory disease or diabetes, to name a few, care is a daily challenge and it’s important to follow up these patients and get their parameters on a day-to-day basis so we can evaluate patient specific trends and deviations.

mHealth can make a huge contribution in areas where specialists or general practitioners are nearby in this sense. By getting accurate patient data, we can gather the information that can lead to early interception and faster intervention by using algorithms that pick up a worsening of diseases, enabling a simple intervention with medication instead of a hospitalization, with all the resulting benefits for the patient as well as for society.

Take the example of diabetes and the flash glucose measuring devices. You probably have seen that some patients have this kind of small sensor in their upper arm that continuously measures their glucose values. By flashing the smartphone over the sensor, the data becomes accessible on the patient’s smartphone and can be shared with the hospital. This technology has a huge positive impact for patients, making it easier to daily manage their diabetes. I speak from my own experience.

However, I think that the implementation and the use of this new source of information could be optimized. Health professionals only consult these remotely measured data when the patient is in the doctor’s office. In an ideal situation, a diabetes nurse or smart algorithm could triage between patients that really need specialist help, and patients that are doing fine and don’t need to go to the hospital. It’s not just about costs, it’s also about better care and the work of specialists. Patients with values that are way out of range, maybe should go more to the specialist than patients 90% in range. That makes the level of care more efficient and logical. Nothing so frustrating than traveling to the hospital and waiting for the specialist to hear everything is fine, while your diabetes management app could tell you exactly the same.

In other words: while mobile health offers great benefits it’s important to do it right, properly implement it and properly reimburse it or otherwise we will have new technology on top of an old way of organizing care.

Can you give the example of a successful mobile application that found its from bench to bedside within the Mobile Health Unit?

A nice project that you might know since it has received quite some media coverage is the FibriCheck application. It is the first Belgium-made medical smartphone application that was CE-certified and has FDA certification as well.

It started in the Mobile Health Unit, in 2013, out of a student project in Hospital East Limburg. The project revolved around the detection of heart rhythm disorders like atrial fibrillation (AF). AF doesn’t always have clear symptoms, so many people are not aware of it. But treatment of AF is key to prevent strokes. Detection is challenging as the abnormal heart rhythm may occur for a certain period and then turn back to a normal rhythm. That’s why patients often get a holter for a 24 hours ECG registration at home.

The question was if we couldn’t do something for these patients and we started a student project on the feasibility of a smartphone application to detect arhythmias. In the beginning it was more a technical project focusing on the PPG signal quality and developing algorithms. In 2014, this foundation was further developed into an application to automatically detect and assess the heart rhythm. That year, the research project was selected to participate to the ‘Health Ideator’ workshop of Microsoft Innovation Center, shortly followed by the nomination for Bayer’s Grants4Apps incubation program in Berlin for 100 days. That’s when my former colleague Lars Grieten, in the summer of 2014, took the initiative for the foundation of Qompium.

For medical use in patients, it was essential that the results of this PPG based smartphone application were as reliable and accurate as the current clinical (gold) standards and so the application was extensively validated in many different clinical trials and projects. In 2017, FibriCheck was one of the 24 mhealth pilot projects supported by the Belgian Government and RIZIV to investigate the clinical implementation and a reimbursement model for mhealth services.

So, this is a nice example of how research is translated into a real and useful application, with already more than 125.000 users. Patients can download the app from the app store to use the software themselves and doctors can prescribe it, for instance to patients with a higher risk or to patients that had a medical intervention like an ablation or a kind of electroshock. It enables doctors to see if the rhythm disorder has really disappeared, if it comes back and if the treatment was effective.

Since a heart rhythm disorder can sometimes lead to a stroke the prevention aspect is important too and obviously with the app you can screen many patients and avoid the costs of in-hospital ECG examinations. So, the application offers quite some added value in many regards, it is low cost, convenient for the patient and highly accessible.

What makes mobile health applications work

What makes an mHealth application successful?

It seems logical, but I think a successful mHealth application needs to be problem-driven. Sometimes we see companies that have solutions but that don’t really solve problems of patients, clinicians, hospitals or other stakeholders.

Yet, there needs to be something behind the application that really makes a difference for one or more stakeholders, so they want to pay for it. Keep in mind that in Belgium patients are not used to pay for health care given the already high amount of taxes. And the government is focused on short term revenues.

There are many mHealth applications in areas such as fitness and wellbeing that also have their value, but you can’t really compare them with medical apps that have a proven medical and socio-economic benefit such as apps that support a personalized and comprehensive cardiac rehabilitation program at home.

For example, Jessa hospital is a European leader in tele-rehabilitation strategies with many peer reviewed publications on the added medical value and the cost-effectiveness. Together with EDM (Expertise Centre for Digital Media) of Hasselt University, they partner in a seven-year H2020 project on personalized prevention for cardiac patients. This project is a fantastic opportunity to scale and implement a comprehensive tele-rehabilitation application which will be fully personalized, and which will evolve according to the preferences, the medical and the social context of the patient.

This is an example of a tool that has a clear proven benefit and improve the life of the patient in a personalized way which is less the case for many other applications that exist.

And then there is the use experience. Take an application for therapy adherence, for instance. I used one myself but each day you need to manually enter data about whether you took your medication or not and after two weeks you kind of get tired of that so, I think that it’s not just about clear added value for the user but that it also needs the least possible effort from patients so they will actually keep using it.

It needs to be convenient. For example, sensor technology needs to have an unobtrusive form factor and a passive way of collecting patient information.

We did research on patients with pacemakers and implanted cardiac devices that really collect lots of data automatically, so the patient doesn’t have anything to do. That’s the ideal situation: effortless high-quality data in a continuous way.

Of course, that’s not always possible but striving towards the least possible patient action is key. As mentioned, we work closely together with imec that is specialized in several types of patches that collect reliable patient data without patients needing doing any effort and I think that effortlessness makes a huge difference. This sensor technology will be embedded in patches, clothes, bracelets, or even in your environment like your car seat or mirror.

You also need to communicate with the patient. All the relevant information that gets extracted from the raw data obviously needs to lead to actions and outcomes. Yet, you also need to provide actionable feedback to the patient on what the information means and what actions can be taken to improve their health, daily care or medical situation. Patients expect that.

Actions for the government

We have some speakers from the government, what would you say to the Belgian politicians who are responsible for healthcare?

I would definitely focus on the reimbursement of tele-monitoring services.

It is a good evolution that for type I diabetes flash glucose monitoring ‘technology’ is reimbursed. But that is not enough. The government needs to go a step further and create financial incentives for hospitals and medical professionals to shift towards remote follow-up of their patients leveraging digital technology.

Same story with implantable cardiac devices, the technology is reimbursed, but not the service to remotely check the disease and device parameters in order to support patients from a distance. This leads to the situation that patients need to come to the hospital for evaluation of their data, while they are remotely accessible. These unnecessary consultations could be avoided, costs saved, and patients satisfied.

So, politicians need to be brave and grab the opportunity to financially incentivize medical professionals to implement a digital service exploiting all possibilities of the digital technology. This will accelerate a patient-centered and demand-driven care model which is personalized, preventive and more efficient.

A full version of this interview is available here.