The idea of using communications technology in health care delivery has been popular for about 30 years but the benefits of telemedicine, and its mobile phone sibling, mHealth, are yet to materialize.  While the high-cost medical sector of the developed world inches toward using communication technology to lower costs, governments, international agencies, nongovernmental organizations, and a few for-profit companies are attempting to use technology to deliver minimum levels of care in the developing world.  Conferences (e.g., mHealth Summit), initiatives (e.g., USAID Mobile Alliance), academic projects (e.g., Open mHealth), consultants (e.g., DiMagi), and student-initiated ventures (e.g., Click Diagnostics) abound, but, as usual, I wonder what effort may have demonstrated success in delivering an improvement to health affordably, that is, at a price people are wiling and able to pay, since my prejudice, possibly mistaken, is that a proven business model is a powerful way to effect large-scale change.

Here in the US, where most care is paid for through third parties (the government or insurers), a handful of start-up companies see a business opportunity in substituting “teleconsultation” for doctor visits, the idea that we harried insurees are more likely to use our cell phones (or computers) to address minor, non-emergency health concerns than to see a doctor, before the problems become serious and more costly to treat.  These companies offer phone consultations with physicians who provide advice, recommend treatment options, and prescribe medication when appropriate.  Examples are Consult-a-doctor (Consult), Teladoc (Teladoc), and Easy Health MD (Easy Health).  The leading company, that is, the one that looks like it will be profitable in the near future is American Well (American Well) which has built an online system that connects consumers with physicians immediately and for physicians to connect to specialists in real time.  The company is four years old and has 90 employees and four large providers as customers:  Hawaii Medical Service Association, the Hawaii franchise of Blue Cross Blue Shield; Blue Cross Blue Shield of Minnesota; OptumHealth, a unit of private health insurance giant, UnitedHealth Group; and TriWest Healthcare Alliance, a Phoenix-based health plan for military personnel and their families (Xconomy article).  As the name implies, all well and good for the US where 16% of the GDP involves health care, but what about the rest of the world?  (I should note that in the above-cited article the American Well CEO says the company is considering how to expand internationally into underserved markets.)

Googlin’ about, I found that the developing world complement to US teleconsultation is the “health hotline” and an excellent 2009 report on its use and potential by the GSMA Development Fund (GSMA DF) which is part of GSMA, the trade association of mobile phone service providers.  The report, called “A Doctor in Your Pocket” (GMSA DF report), points out that health hotlines are used by more than 10 million people in Mexico, India, Pakistan and Bangladesh and new systems are being set up in the Middle East, the Caribbean, Latin America, and Southeast Asia.  Moreover, most have a for-profit model and typically involve a government agency, healthcare provider, and a mobile phone service provider.  The report focuses on four established systems and provides useful data on use, scaling, staffing, customer satisfaction, challenges, and opportunity for and limits to growth.  Some additional interesting points are:

  • the hotlines handle up to 50,000 calls per day;
  • calls are answered by a mix of medical professionals and trained agents, e.g., MedicalHome in Mexico uses 15 doctors and 100 agents per shift to answer 10,000 calls per day;
  • the users are about 50/50 rural or urban poor and middle class;
  • revenue is by fee per call (two of the four) or monthly subscription;
  • all are affiliated with health care providers and in some cases offer discounts on services;
  • liability is not seen as a major risk and in part because medical malpractice suits are rare; and
  • potential revenue is through fees to outside providers for referrals and prescription issuing.

The bottom line of the authors is that while such hotlines are improving the access to medical care for under-served populations, especially the rural poor, there are constraints to increasing their scale, including operational challenges and affordability, and that some regulation (standard-setting) is needed to support market growth.

The authors did not address the investment opportunity and start-up activity but I would think that most of the GSMA’s members have developed or seen medical hotline business plans.  Apparently, one of the report’s author wrote on of these plans since he, along with three others, started a company in India in May of this year, mHealth Ventures (mHealth Ventures), which is offering a subscription-based service called Meradoctor.  It has two low-cost plans and about 900 families as customers to date (USAID blog post).  One opportunity is for the top-tier, rest-of-world hospitals and medical centers to expand their patient base to their countries’ mid- and low-income groups through a patient hotline.  After all, there are just so many wealthy locals and medical tourists to treat.


One thought on “mmmmmHealth

  1. Very interesting topic, Chris, and great research on the different thoughts and approaches to this. The standard medical dictum about diagnosis is that it is 90% history, and only 10% physical exam–certainly my experience as a primary care physician would agree with that ratio. So simple telephone consults should in theory be reasonably accurate (I will leave aside more advanced technologies that are being developed for true telemedicine with video, blood pressure, pulse, and temperature readings, etc). Even in the 90’s managed care companies were putting together treatment algorithms that nurses could use to answer simple questions. For example patient has sore throat–ask if she has fever, swollen nodes, difficulty swallowing, etc. OF course, sore throat is one of the classic no-brainer examples, along with simple stuff like a twisted ankle, diarrhea, a cold or cough, a urinary tract infection. These are generally low risk/low complexity complaints and can be assessed reasonably well by asking the right questions. Another standard medical dictum is that common things occur commonly, sometimes expressed as ‘ïf you hear hoof beats, think horses, not zebras” (at least that’s what we say in the US!) You will usually be right when identifying a common condition, but need to be aware of “red flags” or worrisome symptoms that need further investigation. A prime task of primary care is separating the common stuff that is often self-limited from the more serious illnesses. These ‘red flags’ are built in to algorithms that telephone consultants use, and in such situations the patient is directed to seek care locally.
    So I think telephone consultations, given good decision aids i.e. algorithms, can really perform important basic evaluation. In a limited resource area that is much better than what they currently have. But I haven’t reached the point yet where I am worried whether I will have a job in the future! I already do telephone consultations all the time, when I am on call. I will be on call for my group, so get calls both from my own patients and from others. I know when I do a phone consult it is more satisfying for me, and for the patient, when it is one of my patients whom I know. There is in fact a level of trust that having a relationship gives when giving advice. Also that I stand behind that advice, I will be seeing them if they do not get better. In practice, I find it’s awfully easy to avoid trying to really understand a problem and to tell someone to follow up with someone else. It’s a put off, and people know it. And I think a common final advice line given in the tele-consult is “follow up with your doctor.”
    Another issue is that patients are increasingly complex–they have chronic illnesses such as HIV/AIDS, transplants, diabetes, asthma, post-cancer. They have had medical or surgical procedures. They are on multiple medications and may not know the names of the medications. To be of much use for these patients, the tele-consult will need access to their medical record. That is certainly possible, especially as we are now going to electronic medical records. But it also means that the tele-consult may need access to their own consultant to answer complex questions.
    My own preference would be to encourage telephone and email consultations, but to have them provided by the primary care office rather than a third party. The current issue of that of course is reimbursement. I am paid nothing for a telephone or email consult. But there are vertically integrated systems (e.g. Group Health in Seattle) that do consider this important work, and an important service to offer their patients. And, in fact, a money-saver, especially if you consider the patient’s inconvenience of having to take time off work, come in, wait to be seen. And potentially attractive to primary care doctors, too, if reimbursed. Most primary care doctors I speak with spend 1 1/2-2 hours at the end of every day (or during lunch) calling patients or doing paperwork associated with the practice.
    Thanks for the article that stimulated me to think more about this! Keep on blogging!

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