2012 mHealth reportfrom Ruder Finn London

Contents

3 Viewpoint

4 The industry landscape

6 Healthcare applications for consumers

9 Healthcare professionals

13 About Ruder Finn Healthcare Technology

Viewpoint

As global populations age and many elderly people live with chronic diseases, society needs measures to manage this changing demographic of healthcare users.

Taking healthcare to the patient, putting them in control of their illnesses and enabling them to live more independently, are ways to ease the burden on healthcare systems. Mobile healthcare (mHealth) promises just that.

Technological advances mean small, lightweight and highly connected devices are in the hands of much of the population. These

devices – smartphones and tablet computers – have been widely adopted, mainly because of their increased connectivity, ease of use and long battery lives. Couple this with the “app” model, where users can pick and choose from thousands of applications for their devices, and these platforms become prime candidates to manage at least one aspect of people’s lives – their health.

Many such apps already exist and use a variety of sensing inputs to inform the user of different aspects of their health – e.g. the built-in camera to measure heart rate, tri-axis

accelerometry to measure levels of activity, etc. Some apps use the fact that these devices have Bluetooth or other means of connecting to specialist hardware to great effect – e.g. BT blood-pressure monitoring or weight management scales.

We have a technology that is highly useable and almost ubiquitous; a population that is tech savvy; and illnesses that are quite treatable but require longer term observations and care, points addressed by the mHealth revolution we see today.

In the future, we can expect battery lives to become onger,

devices to be smaller and lighter, wearable even, and connectivity to be faster and more reliable. With new sensing technology, most probably implantable, it's not too much of a stretch to imagine mHealth becoming a part of our everyday lives, increasingly not only to manage illnesses but to keep us well for longer.

Prof. Christopher JamesProfessor of Healthcare Technology & Director, Institute of Digital HealthcareWMG, University of Warwick

The industry landscape

The healthcare technology team at Ruder Finn commissioned research by YouGov to get a snapshot of consumer attitudes to mobile health both as users and as patients.

The results, compiled within this report, examine what we currently use, which services we want and our attitudes to the prospect of healthcare services being delivered remotely. More than a thousand smartphone and tablet users from across the UK were surveyed in June 2012 and their responses provide some interesting insights, which help inform the way technology

platforms and applications for healthcare delivery could be designed moving forwards.

Mobile innovation

Mobile is the most widespread communication infrastructure in the world. Most of the world’s population has access to some form of mobile communication and mobile healthcare – or mHealth – describes the use of this infrastructure in the transformation of societies’ healthcare services.

The potential advantages of

integrating mobile technologies into the healthcare service delivery model are clear: better services to a larger number of patients; easily standardised care through centralisation and IT developments; and greater collaboration to provide integrated care by sharing patient data with all parties involved.

mHealth services have the potential to further improve quality and access to care as well as reduce costs in both developed and emerging markets.

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Smartphone and tablet apps

Analysts predict that the smartphone application market - one of the fastest growing sectors of mHealth - for mHealth will reach US$1.3 billion in 2012 with 247 million users downloading an app worldwide. This demonstrates a significant increase compared to the 124 million users who downloaded smartphone health applications in 2011.¹

In the UK, we are adopting new technologies at an increasing speed. Since the turn of the decade there has been an explosion in smartphone ownership such that more than a quarter (27 %) of UK adults now own one.² This rises to four fifths (81%) among healthcare professionals.³ The rise in ownership is set to continue

as contract packages make smartphones more affordable and as our love affair with smartphones continues, so does our appetite for mobile applications (apps).

At the same time the tablet market is booming. Sitting somewhere between the smartphone and the laptop, the tablet is designed almost exclusively for the delivery of tools, services and media via touch screen. Already widely used in some hospitals for recording and sending patient data, as a platform the tablet has the potential to deliver a far greater array of healthcare services – from virtual consultations to monitoring changes in the body and enabling patients to input their

own data and upload it remotely.The opportunities these new

platforms create for services to be delivered in an entirely new way have been recognised by technology and telecoms / mobile vendors. Companies are investing millions to develop new apps and services – both for the consumer and for the healthcare professional – but does the demand warrant such investment?

There is no doubt that mobile apps are incredibly popular – this year downloads from Apple’s App Store exceeded those from iTunes for the first time. But is there a market for health apps? And do consumers want to have healthcare services delivered on mobile devices?

¹Research2Guidance. mHealth App Market Trends and Figures 2011-2016. January 2012

²Ofcom Communications Market Report: UK August 2011

³Manhattan Research 2012

Top three reasons for not using a health app • I have no need to access health

related apps• I prefer to talk to my doctor

(healthcare professional) in person about any health related questions

• I do not find health apps to be helpful

"These results suggest smartphone owners and users believe that smartphone technology can help with keeping doctors in touch with and up to date with a person’s health status."

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Not all platforms are created equal

According to the most recent Ofcom Communications Market Report², just under half (47%) of adult smartphone users have downloaded an app. But while we’re busy downloading, research suggests the majority of apps, once downloaded, are only used once and then left idle.

Usage of apps, once downloaded, is an important factor for this market. In 2011 a quarter (26%) of downloaded apps were used once.⁴ However, the Ruder Finn research supports a Localytics’ report that shows the iPhone and iPad had retention rates 52% higher than those on Android. In addition, the average Android app has a 24% one-time usage rate compared to just 21% one-time usage rate for iPhone

and iPad.⁵ The research suggests that in the world of health apps, not all platforms are created equal. It seems that regular users of iPhones and iPads are more likely to use health apps than regular users of other types of smartphones and find the technology easier to use.

Also, while use of health apps was lower than nearly all other types of apps listed, usage of health apps on iPhones was three times higher than on Blackberry and twice that on Android OS.

Regardless, the rise of smartphones has sparked a flurry of activity in the development of health apps. Samsung has released its S Health app for the Samsung Galaxy S III, which collects a variety of data

about the user to help maintain a healthier lifestyle. In India, Vodafone has launched “Ask a doctor” that enables users to clarify health-related questions with doctors using their phones.

An appetite for health apps

But while the device makes a difference to whether or not people will regularly use the app, the Ruder Finn online survey shows that respondents in general would be interested in using health apps or services. App publishers take note: the public wants apps but you’ve got to make them usable.

But in answering this particular question, more than a third of

Healthcare applications for consumers

*mHealth: Consumer Attitudes Survey of 2,000 consumers (RuderFinn/ YouGov June 2012). Responses to: Which application would you be interested in using?, and which of the following health services would you like to be able to access on your smartphone or tablet?

⁴ Localytics 26% of Mobile Application Users are Fickle — or Loyal. March 2011 http://www.localytics.com/blog/2011/26percent-of-mo-bile-app-users-are-either-fickle-or-loyal/

⁵ Localytics App retention increasing: iPhone crushes Android (June 2012)

"Owners of iPhones and iPads use health apps more frequently than users of other types of smartphones."

Applications smartphone users are most interested in*

Fitness / training apps

Apps to make appointments with

your GPApps to view your personal

medical recordApps to access test results

iPhone

Blackberry

Android OS

27% 20% 23%

Calorie counter apps Healthy eating apps

24% 20% 24% 22% 17% 20%

48% 34% 47% 40% 21% 29% 39% 20% 31%

respondents (36%) said they would not like to access any health services via an application on their smartphone or tablet. This finding, however, hides some differences related solely to devices.

Just over a quarter (27% & 26%) of regular iPhone and iPad users said they wouldn’t use a health app on their phone or tablet, compared to two fifths (42%) of regular Blackberry users, more than a third (35%) with an Android OS, and a quarter (27%) with another type of tablet.

Taken in the context of the rest of the survey, this answer suggests that Blackberry users find using apps on their devices not worth the bother.

However, the popularity of smartphones, the fact they go everywhere with their owner, and are rarely switched off means they are

the ideal way to deliver applications that deliver support, monitoring or information for patients. And their ubiquity means companies developing for smartphones are not expecting people to invest in yet more technology.

Our research showed more than a fifth (21%) of respondents were very likely or fairly likely to use a service, delivered via mobile technology, to better manage their health.

But it’s the companies with the efficacy studies, apps that work across the range of technology, and companies that build into their apps support to help consumers change their behaviour, who will ultimately lead this market.

The take home message from this is that while a quarter of adults (27%) and almost half of teenagers

(47%) own a smartphone, not all smartphones offer their users the same level of flexibility when it comes to apps. Those makers of apps who ensure they work easily across a variety of platforms are the ones who are going to be successful. This is critical information for developers and endorsers, such as the NHS, which is planning to let doctors know of 500+ apps it can recommend to patients to help them manage their health (while cutting costs for the NHS). Recommending which platforms to use will be critical.

Apps currently available

It seems not all health apps already launched have been useful; earlier this year researchers found that patients who used smartphones to

⁷ Ryan D, Price D, Musgrave SD, et al. Clinical and cost effectiveness of mobile phone sup-ported self monitoring of asthma: multi-centre randomised controlled trial. BMJ. 2012;344:e1756.

"The popularity of smartphones, the fact they go everywhere with their owner, and are rarely switched off means they are the ideal way to deliver applications that deliver support, monitoring or information for patients."

rural and urban dwellers. The reasons given by those living in the country for not using apps were the same as those living in the inner city, towns and suburbs. Those in rural areas were broadly interested in the same kind of apps as those living in cities and suburbs, namely calorie counters, healthy eating and nutrition apps.

The one difference was fitness apps. A fifth (22%) of all respondents said they would use a fitness app if one were available; this figure dropped to just 16% among those who lived in rural areas and 10% villages. Perhaps the hike from the shops home, now that rural bus services are non-existent, mitigates against the need for digital fitness help.

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health apps. More than two fifths (42%) of those with smartphones/tablets who hadn't used a healthy living app in the previous six months said they had no need for health apps and a fifth (19%) of respondents said they’d rather speak with their doctor. When broken down these baseline figures reveal that young people are the ones who don’t feel they need health apps. Just over a quarter (28%) of those over 55 felt they had no need to access a health app. There’s a similar age divide in relation to preference to speak face to face to a doctor; a third (33%) of the over 55s preferred personal consultation but only a tenth (10%) of those aged 18/24 felt the same.

Among the respondents who described themselves as having

a chronic health condition, there was only a third (32%) who felt no need for a health app and just over a quarter (27%) who preferred to talk with their doctors. This latter finding suggests that while those with long term health conditions are keen on apps to manage their health, it won’t necessarily free up time with healthcare professionals and save the NHS costs. If a health service is hoping for cost saving as well as improving people’s health by using mHealth then the trick will be to develop apps that not only offer people the ability to manage their health but also provide an element of contact that comes with a visit to the GP.

One variation that we had expected but our survey results did not show clearly, was that between

monitor their asthma, were not able to improve control of their disease any better than paper monitoring.⁷ Some apps may even need regulation and approval. In May, doctors at the Mersey Regional Burns and Plastic Surgery Unit certified their Mersey Burns iPhone app as a medical device. It seems the rule of thumb is that if the app is used in clinical decision-making, then it is most likely a medical device.

But despite these drawbacks, results from our survey make it clear there is huge potential for health apps delivered via a smartphone.

Not APPropriate for everyone...

Our data show some interesting trends in why people don’t use

Who’s using what?

Among all our respondents, only 7% had used a general health and lifestyle app in the previous six months; of those who said they had a chronic disease/health condition 11% had. In general, there was little difference in the use of health apps between the apparently healthy and those with chronic conditions.

When asked why respondents had not accessed health or lifestyle apps in the last six months, again, the difference between those who identified themselves as having a chronic disease/health condition and those who didn’t was not marked. Two fifths (42%) of all respondents said they had no need for health apps compared to a third (32%) with long term conditions a fifth (19%) of all respondents said they’d rather

talk with a doctor compared to 27 % of those with chronic disease/health; and roughly a tenth in each group (11 % of all respondents and 10 % of those with chronic disease/health) said they didn’t find health apps useful.

The two groups had roughly the same wish list for apps. The most popular (42% of respondents; 46% of respondents with chronic disease/health conditions) was one that would make appointments with the GP. There was also some enthusiasm for being able to access test results, with about a third of each group saying they would use an app like this.

The biggest difference between these two groups of respondents were in the apps around managing

conditions with nearly twice as many people with chronic disease/health conditions interested in apps for monitoring conditions or managing medical services. If companies can get these kind of apps right then there is a real opportunity to improve people’s ability to manage their health.

Our online survey indicates that a majority of respondents with chronic disease/health conditions are interested in apps; these new adopters may well be the vanguard of patients who will help pioneer binary network apps (apps that track peripheral devices), seen by many analysts as the biggest trend in 2012. Wearable censors, apps that diagnose using smartphone technology are likely

to be of interest to the quarter of respondents (24%) with chronic disease/health conditions who said they were interested in monitoring their health.

A healthcare professional tool?

The mobile nature of many medical practices – GPs visiting patients, specialists moving through a hospital, paramedics in the field – means that mobile communications have always been of interest to these professionals. Doctors, in particular, are often early adopters of new technology and have embraced smartphones and tablets with enthusiasm. Manhattan Research, which monitors

Healthcare professionals

Healthcare services smartphone users are most interested in*

0

100

50

75

25 23

All respondents

Reminder apps that tells you when you need

a repeat prescription and reminds you when to take your medication

per c

ent

Monitoring apps for long term conditions

Medication management apps

All respondents identifying themselves as having a chronic disease or health condition

33

9

1712

24

10

healthcare professionals’ adoption of new technology, has found that 26% of European doctors now have and use an iPad professionally, spending a quarter of their online time using the device.⁸

A recent US study found smartphones were popular for clinical use among clinicians, and medical and nursing students, facilitating access to clinical information at the point of care; drug reference apps, medical textbooks, references for disease diagnosis, and medical calculator applications were reported as most useful by clinicians and medical and nursing students.⁹

We asked our respondents which apps they thought would be helpful for healthcare professionals. The results suggested a divergence

between what they were willing to use compared to what they thought doctors and nurses could use to improve healthcare.

The top three ranked apps for healthcare professionals, as rated by all respondents were: access to test results; smartphone and tablets that enable doctors and nurses to record observations and share information while away from the surgery/ hospital and virtual consultations for people living in remote areas; and an app that provides information to doctors about a patient’s health status via the monitoring device in patients’ homes.

These results suggest smartphone owners believe mobile technology can help doctors keep in touch and up to date with a person’s health status, enabling the professional

to take action should somebody’s health deteriorate. But there is little to suggest people are expecting a health revolution based on GPs using apps to improve and change patients’ behaviour.

There was little difference in the ranking of these three apps based on where respondents lived, whether they had a long term medical condition, or their age. What the results do suggest is that the respondents may not have considered privacy or transfer of data over mobile networks as a potential issue. This lack of concern is mirrored by the 30% of respondents who said they would like to be able to use an app to view their medical records from their mobile phone and the 31% who wanted access to their test

*mHealth: Consumer Attitudes Survey of 2,000 consumers (RuderFinn/ YouGov June 2012)

⁸ Tryer D. Twenty six per cent of European doctors own an iPad. February 15 2012 http://www.pmlive.com/digital_intelligence_blog/archive/2012/feb_2013/european_doctors_ipad_use_ownership

⁹ Mosa AS, Yoo I, Sheets L. A Systematic Review of Healthcare Applications for Smartphones. BMC Med Inform Decis Mak. 2012;12(1):67.

"If companies can get these kind of apps right then there is a real opportunity to improve people’s ability to manage their health."

Top three apps for doctors & nurses • Monitoring devices that can alert

carers, doctors and nurses if a patient has a health emergency

• Access to test results• Smartphone and tablets that

enable doctors and nurses to record observations and share information while on home visits or away from the surgery/ hospital

results via a health app. But the app the respondents were most likely to use was a purely practical one – more than two fifths (42%) wanted an app that would let them make an appointment with their GP.

The practical challenges of making apps indispensable to healthcare professionals are multiple. Useability and platform are concerns, but there are also very practical considerations for a doctor on the move – battery life, size of the screen, security, how to input data. The app is only as valuable as the information in it and, as with all healthcare information, it will need to be updated regularly, especially resources for professionals such as disease diagnosis, drug reference, and medical calculator applications.

Real life Application

Using mobile technology to improve the well being of people with long-term medical conditions has long been an aspiration for healthcare providers. Of the various mobile-enabled services, remote health monitoring (RHM) could have the greatest impact on chronic disease management. RHM services are likely to deliver the greatest benefit in terms of improved disease evolution, patient lifestyle and treatment costs by enabling providers to improve:• Disease diagnosis, complication

management, and intervention ahead of acute phenomena

• Treatment compliance through patient/caregiver reminders

• Quality of care by giving patients and caregivers tools to manage

disabilities associated with chronic disease, e.g locator devices for dementia patients

• Patient data collection and analysis• Quality of life by keeping patients

out of hospitals and nursing homes Our research results paint a complicated but informative picture of the market for mHealth. There is no question that mobile devices – whether tablet or smartphone – are changing the way we interact with many services already.

However, the fact these devices are relatively new and the most sophisticated users of them tend to be the younger generations, means trying to predict take up of mobile device- based healthcare services (both consumer and clinician driven) in the future is difficult.

What we can see are some

"There is a difference between interest and use. 50% more respondents said they would be interested in using healthcare apps as currently use them."

very interesting trends that both healthcare application developers and those that deliver healthcare should note:• Gamification is something already

being looked at as a method for engaging and educating consumers – why not patients? Gamification could also help solve the problem of idle apps by increasing engagement and helping to ensure apps are not just downloaded and then ignored.

• Platform is important. The numbers using healthcare apps changes significantly depending on the platform. This may be to do with the profile of the users but is healthcare application development skewed towards Apple devices? App developers

should consider that Apple has a 16.9% share of the smartphone market while Android has 36.4%.¹⁰ In the tablet market things are very different. Apple’s share is almost 70%.¹¹ As Android becomes more aggressive in this space, however, we can expect that to decline.

• There is a big difference between interest and use. Twice as many respondents said they would be interested in using healthcare apps as currently use them. This tells us there is demand that is not currently being met.

• Interest is highest in tools to help consumers manage their interactions with healthcare professionals and give them visibility and control of the information about their health. This

suggests consumers welcome tools to make life easier but not at the expense of face-to-face interaction with healthcare professionals.

As the social generation gets older there is little doubt that we can expect to see usage of mHealth tools and applications rise. The winners in development will be the companies who learn why apps are being used now and apply those lessons to future development.

The idea that mobile is a panacea for reducing healthcare costs and improving efficiency is a false one. The delivery of healthcare services through mobile devices must always been seen as an adjunct rather than a replacement. A mobile will never take the place of one-to-one interaction with an individual doctor.

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"The idea that mobile is a panacea for reducing healthcare costs and improving efficiency is a false one."

What we found & what it means for app developers • Consumers online want apps to help them manage the practical aspects of

healthcare but they need to be easy to use and accessible on all platforms• Although usage is relatively low, interest is high. Developers need to

understand why smartphone users aren’t engaging with health applications• Consumers using Apple devices are the most likely to use health apps.

Developers need to understand why… is it the profile of Apple users or the apps themselves? What impact does the platform have on usage overall?

• At the moment health apps are the least popular while social media apps are the most popular. Age of app users has an impact but what can developers learn from games and social media apps to make theirs more compelling?

• A fifth of our respondents said they were likely to use a health app before the end of the year. The market is there and it is growing but the apps need to be compelling enough to compete for mindshare in a tough market

• A third of our respondents would view medical records or get test results through an app. Medical services apps would perhaps have better usage levels than lifestyle apps if made quick, easy and intuitive

¹⁰ IDC Worldwide Quarterly Mobile Phone Tracker. July 2012.

¹¹ CNET: Apple dominates tablet market in Q2 with 70% share. August 14, 2012.

RF Healthcare Technology brings together two of our agency’s specialist practices to create a single global division that helps IT and pharmaceutical companies realise the potential of technology as a tool to improve healthcare delivery – both for clinicians and consumers. Clients include technology giants such as Microsoft and Fiserv as well as leading pharmaceutical companies including Novartis and Pfizer.

Ruder Finn

Ruder Finn is one of the world’s leading independent communications agencies, with offices in EMEA, US and across Asia. Headquartered in New York, the company supports a broad range of clients across four strategic pillars that reflect its

experiential elements to prepare for delivery and launch

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About Ruder Finn Healthcare Technology

key areas of leadership: Health & Wellness, Corporate & Public Trust, Technology & Innovation and Consumer Connections. Its regional headquarters are in New York, London and Singapore and the agency is also the second largest in China with four offices in Shanghai, Bejiing, Hong Kong and Guangzhou.

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DEFINEBrief and objectives : Ruder Finn’s senior team uses your brief as a

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DISCOVERData & insights: Combining primary research, desk research and industry leading tools with a full range of social media, offline media and campaign planning tools to deliver the insight needed for campaign planning

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All figures, unless otherwise stated, are from YouGov Plc. Total sample size was 2148 adults of whom 1204 have access to a smartphone/ tablet. Fieldwork was undertaken between 26th -29th June 2012. The survey was carried out online. The figures have been weighted and are representative of all GB adults (aged 18+).

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