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mHealth US end-user research: Beliefs, barriers, success factors and recommendations

Prepared for the GSMA by Ipsos Healthcare November 2012

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Background There is considerable excitement around the potential for mobile health solutions (mHealth) to have a significant impact on the management of health across the world. It has been estimated that the mHealth industry may be worth up to US $30bn by 2015. In order to maximise the potential of mHealth, it is imperative that solutions are developed and mobilised with the needs of the end users at the forefront. Solution design should start with an understanding of the current challenges facing healthcare practitioners (HCPs), patients and consumers. The purpose of this paper is to provide an understanding of: The needs of HCPs, patients and consumers in the US, Their beliefs in the benefits of mHealth, Barriers to greater usage, and Assessment of key success factors.

Research Objectives The GSMA wished to address the following objectives: Understand the challenges that HCPs, patients and consumers currently face regarding the management of chronic conditions and peoples overall health Discover whether these end users believe in the benefits of mHealth and understand the nature of these benefits Understand barriers to end user adoption of mHealth and ways to overcome them Identify critical success factors for developing mHealth solutions The GSMA commissioned Ipsos MORI to conduct research amongst potential end users of mHealth to address these objectives.

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Research Approach Respondents: The research incorporated seven end user groups: Secondary care HCPs: Cardiologists Diabetes specialists Primary care HCPs: Primary care practitioners (PCPs) Community nurses Chronic patients with: Cardiovascular conditions Diabetes General wellness consumers: Adults with a high level of interest in health and wellness who do not suffer from a chronic health issue

Methodology and Entry Criteria: Qualitative Phase: Ipsos conducted 2 focus group interviews (6 respondents per group) with each of the 7 end user groups (14 groups in total), providing in-depth exploration of the perceptions and usages of mHealth. The interviews were conducted face-to-face between 6th and 9th March 2012 in New York and Philadelphia. Respondents were screened to encompass a broad range of ages (chronic patients/consumers) and professional experience (HCPs) Respondents were provided with a definition of mHealth and exposed to examples of potential applications and solutions Quantitative Phase: Ipsos conducted online surveys with the 7 end user groups, providing quantitative validation of themes uncovered during the qualitative phase. Sample sizes were as follows: 50 cardiologists 50 diabetes specialists 50 PCPs 50 community nurses 100 diabetes patients 100 cardiology patients 100 general wellness consumers The interviews were conducted between 22nd May and 16th June 2012. Respondents were screened to encompass a broad range of ages (patients/consumers) and professional experience (HCPs). Respondents were provided with a definition of mHealth and exposed to examples of potential applications and solutions

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Current Challenges HCPs and Patients: HCPs face far more current challenges related to the management of chronic conditions than patients. On average HCPs note five separate challenges compared to two for patients. Three of the top five challenges experienced by HCPs relate to patient behaviours. Three-quarters of HCPs believe patients have difficulty following diet and/or lifestyle changes, and two-thirds believe patients are non-compliant with medication and fail to maintain appointments. Difficulty following diet/lifestyle changes is also the leading challenge for patients (52%), but in general they do not believe they have issues with non-compliance to medications and appointments. Nevertheless this demonstrates that there is a considerable need for solutions that will help patients to adhere to their treatment and disease management plans. Affordability of care is a common challenge for both HCPs and patients. Two-thirds of HCPs believe their patients currently struggle with the cost of care, an issue also recognised by more than one in three of patients themselves. Both HCPs and patients need solutions that will allow care to be delivered more affordably. The majority of HCPs identify that patients currently struggle with achieving their disease goals, a view shared by one in four patients. There is a need for solutions that can lead to better health outcomes for patients with chronic conditions. Fig. 1: Top Current Challenges for HCPs and Patients in Managing Chronic Conditions
Difficulties following diet/lifestyle changes Difficulties remembering to take medications Difficulties following diet/lifestyle changes Patients struggle with affordability of care Difficulties remembering to take medications Patients struggle to achieve disease goals Patients struggle with affordability of care Difficulties keeping appointments Patients struggle to achieve disease goals Patients lack full understanding of condition Difficulties keeping appointments Patients lack full understanding of condition HCPs HCPs 11% 18% Patients 16% 35% 16% 11% 24% 18% Patients 24% 35% 51% 52% 65% 64% 65% 64% 64% 64% 51% 74% 52% 71% 74% 71%

Consumers: In common with patients, general wellness consumers state adherence to regular exercise as their primary challenge, reinforcing the need for solutions that assist with maintaining a healthy lifestyle. The question of affordability is also paramount, both in terms of maintaining a healthy lifestyle and for medications. Fig. 2: Top Current Challenges for General Wellness Consumers in Maintaining their Overall Health
I find it difficult to exercise regularly 39% I find maintaining a healthy lifestyle is expensive I find it difficult to exercise regularly I find that medication is too expensive I find maintaining a healthy lifestyle is expensive I find it difficult to maintain a healthy diet I find that medication is too expensive I don't know what information to believe about how to stay healthy I find it difficult to maintain a healthy diet I don't know what information to believe about how to stay healthy 30% 29% 30% 29% 37% 36% 37% 36% 39%

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Benefits of mHealth Overall Benefits to mHealth: All end users groups strongly believe that mHealth has the potential to deliver significant benefits. This is particularly so for HCPs with near universal (94%) belief in the benefits of mHealth. Fig. 3: Belief in the Benefits of mHealth
HCPs Patients General wellness customers 67% 78% 94%

see a benefit to mobile health

There are, however, key differences between the end user groups in how they believe mHealth HCPs 94% will be of most benefit. HCPs believe the main benefits of mHealth relate to the ability to drive Patients 67% behavioural change by enabling patients to take greater ownership over their health. In contrast less than 50% of patients perceive these benefits. 78%
General wellness customers

Patients and consumers believe the primary benefit of mHealth to be allowing real-time monitoring see a benefit to mobile health of progress (60% and 64% respectively). Overall, patients and consumers are more convinced than HCPs that mHealth can lead to better quality of care.
64% 50% of both HCPs and patients agree that mHealth can enable patients to take control in the 61% 60% 58% 54% 55% 54% 53% management of their own condition through better understanding. In addition, almost 51% of 50% 52% 51% 49% 49% 49% 46% 43% patients see mHealth 46% allowing better management of health information and reduced outpatient as 43% 41% 41% 40% 40% consultations. Only a minority of HCPs agree with the latter benefit and 40%34% believe it will improve 28% information management. 66%

HCPs

Patients

General Wellness Customers

Fig. 4: Top Benefits of mHealth by End User Group

66% greater

Patients take

Motivates Better patient patients to compliance follow58% with medication ownership 61% over health diet/lifestyle 54% changes Modifying Patient Behaviours 43%
46%

Better Allows real time 64% information for diagnosis monitoring 60% of progress and treatment
49%

Better quality of care

55% 54% 40%

52%

Patients HCPs understand condition better

49%

Greater Patients independence for patients

51% 53%

Easier to Reduces need Reduces General Wellness Customers for outpatient manage overall consultations health cost of care information
41% 46% Reducing Healthcare Costs 41% 40% 34% 28% 49% 51%

Improving Care Delivery 43%

Empowering Patients

Patients take Motivates Better patient patients to compliance greater with medication follow ownership over health diet/lifestyle changes Modifying Patient Behaviours

Allows real time monitoring of progress

Better information for diagnosis and treatment

Better quality of care

Patients understand condition better

Greater independence for patients

Reduces overall cost of care

Easier to Reduces need for outpatient manage consultations health information

Improving Care Delivery

Empowering Patients

Reducing Healthcare Costs

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Mapping mHealth Benefits to Current Challenges: HCPs believe that mHealth can address key challenges of patient perceptions and behaviour and difficulties achieving disease goals, but are more sceptical about the potential to make healthcare more affordable. HCPs believe mHealth can be a key support in achieving improved patient health through better disease management and behavioural change. More than 50% of HCPs believe mHealth can directly address patient non-compliance with diet/lifestyle changes, medications and appointments. Similarly, 54% state that mHealth can assist patients to achieve their disease goals. However, only 31% are confident that mHealth can address issues around affordability of care for patients. Fig. 5: Healthcare Practitioners: Challenges with Management of Chronic Conditions and Potential for mHealth to Address

Challenge

mHealth as solution

Patients are non-compliant with diet/lifestyle changes

74%

50%

Perception and Behavioural Change

Patients are non-compliant with medications

71%

56%

Patients miss appointments / do not follow up

64%

64%

Affordability of Care

Patients strugle with affordability of care

65%

31%

Patient Outcomes

Patients have difficulties achieving disease goals

64%

54%

Patients with chronic conditions are less confident than HCPs that mHealth can address their key challenges. 40% of patients believe that mHealth can support and motivate them to follow diet/ lifestyle changes, compared to 50% of HCPs, and 46% believe that Challenge mHealth can be an ally to help mHealth as solution them achieve health goals compared to 54% of HCPs.
52% In line with Change patients are sceptical that mHealth can also be a tool to reduce the cost 41% of Behavioural HCPs, diet/lifestyle changes treatment and management. 29% of patients are confident that mHealth can address this issue. Perception and Patients struggle to follow

Patient Outcomes

Difficulties achieving disease goals

24%

46%

Cost of Care

Patients struggle with affordability of care

35%

29%

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65% 31%

Patient Outcomes

Patients have difficulties achieving disease goals

64%

54%

Fig. 6: Chronic Patients: Challenges with Management of Chronic Conditions and Potential for mHealth to Address
Challenge mHealth as solution

Perception and Behavioural Change

Patients struggle to follow diet/lifestyle changes

52%

41%

Patient Outcomes

Difficulties achieving disease goals

24%

46%

Cost of Care

Patients struggle with affordability of care

35%

29%

Barriers to mHealth Whilst HCPs are the most positive towards the potential benefits of mHealth, they are also more likely than other end users to note barriers to greater usage. HCPs have the potential to be strong advocates for mHealth solutions, but they identify several areas that the mHealth industry must address in order to expand their adoption of these technologies. 56% of HCPs believe there are issues preventing greater usage of mHealth versus 30% of patients and 33% of general wellness consumers. Fig.7: Belief in Barriers to Greater Usage Of mHealth by End User Group
HCPs Patients General wellness consumers 30% 33% 56%

feel that there are currently issues which prevent them from using mobile health more often

HCPs note a range of barriers to increased usage of mHealth. The main barrier to increased HCP Not suitable for all patients 53% usage of mHealth is the belief that not all patients will benefit (53%). HCPs are also worried about Not integrated with my 50% mHealth adding complexity to their practice. 50% of HCPs believe that mHealth will not be current systems interoperable with their current systems, whilst more than 40% believe they will receive too much I am not remunerated for work 48% done with mobile health solutions irrelevant data and mHealth will increase their workload. Nearly half of HCPs also believe they will I notam concerned about receivingfor work done with mHealth, and 40%44% concerned about potential liability be too much irrelevant data remunerated are associated with use of mHealth solutions. I am concerned about
potential liability / litigation Concerns about who will provide technical support 35% 40%

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HCPs Patients General wellness consumers 30% 33%

56%

feel that there are currently issues which prevent them from using mobile health more often

Fig.8: Healthcare Practitioners: Barriers to Greater Usage of mHealth

Not suitable for all patients Not integrated with my current systems I am not remunerated for work done with mobile health solutions I am concerned about receiving too much irrelevant data I am concerned about potential liability / litigation Concerns about who will provide technical support 35% 44% 40% 53% 50% 48%

There is little consensus as to why HCPs believe that solutions are not appropriate for all patients. Nearly 50% of HCPs believe mHealth is not suitable for patients with certain conditions, but equally 33% disagree with this statement. Similarly, 40% of HCPs believe mHealth is not suitable for patients with low education levels, but again a high proportion (30%) demur. Ultimately, ensuring that mHealth solutions are presented in a way that reassures HCPs that all patients can benefit from them will be an important factor for growth. HCPs need mHealth solutions that are customizable and/or sufficiently intuitive for all patient types. Fig.9: Healthcare Practitioners: Barriers to Greater Usage of mHealth: Not Suitable for All Patients
I believe that mobile health solutions are not suitable for patients with certain illnesses I believe that mobile health solutions are not suitable for patients with low educational levels I believe that mobile health solutions are not suitable for elderly patients Disagree Agree

-33

47

-30

40

-43

40

Patients have three primary barriers to increased usage of mHealth. The main issue that prevents further adoption/ recommend My doctor does not use of mHealth solutions is lack of recommendation from their HCP (43%). Developers 43% mHealth solutions must ensure solutions are advocated by HCPs. 30% of patients are also concerned about the privacy Concerns about the privacy of my of their information. Although the research does not suggest privacy is a key concern, mHealth 30% health information developers Lack of knowledge of must be prepared to provide reassurance as needed. Lack of information about mHealth 28% options / insufficient and is is also important,information mentioned by 28% of patients. There is a need for awareness campaigns to promote thewill be too expensivemHealth. 20% mHealth solutions benefits of
Requires a high level of comfort with technology Concerns about the accuracy of information / education 13% 20%

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I believe that mobile health solutions are not suitable for patients with certain illnesses I believe that mobile health solutions are not suitable for patients with low educational levels I believe that mobile health solutions are not suitable for elderly patients Disagree Agree

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-33

47

-30

40

-43

40

Fig.10: Chronic Patients: Barriers to Greater Usage of mHealth

My doctor does not use / recommend mHealth solutions Concerns about the privacy of my health information Lack of knowledge of options / insufficient information mHealth solutions will be too expensive Requires a high level of comfort with technology Concerns about the accuracy of information / education 13% 20% 20% 30% 28% 43%

The primary factor preventing patients using more mHealth solutions is that HCPs do not offer them. However, patients appear to be open to HCPs prescribing mHealth solutions. They do not perceive that HCPs doubt the quality of mHealth solutions, nor their own ability to use the solution correctly. Fig.11: Chronic Patients: Barriers to Greater Usage of mHealth: Not Recommended by HCP
My doctor does not currently offer mobile health solutions My doctor does not recommend mobile health because he/she doubts its quality My doctor does not trust me to use mobile health solutions correctly Disagree Agree

-5

91

-29

24

-57

14

The belief that mHealth will require a high level of technological knowledge is clearly the largest barrier to mHealth usage amongst consumers (49% overall). Underpinning this belief is the perception that mHealth solutions are reliant on the end user owning a smartphone. There is a need for mHealth developers and advocates to ensure that end users are aware of standalone solutions that do not require ownership of or comfort with smartphone technology.

Requires a high level of comfort with technology Lack of knowledge of options / insufficient information Concerns about the privacy of my health information Mobile health solutions are too expensive Concerns about becoming too reliant on mobile technology Not as good as direct contact with a medical professional Concerns about the accuracy of information / education 33% 30% 27% 27% 24% 21%

49%

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Fig.12: General Wellness Consumers: Barriers to Greater Usage of mHealth

Requires a high level of comfort with technology Lack of knowledge of options / insufficient information Concerns about the privacy of my health information Mobile health solutions are too expensive Concerns about becoming too reliant on mobile technology Not as good as direct contact with a medical professional Concerns about the accuracy of information / education 33% 30% 27% 27% 24% 21% 49%

Factors for Success HCPs, patients and consumers agree on three key success factors for increased usage of mHealth. mHealth solutions should be affordable/reimbursed Affordability/reimbursement of solutions was considered important by HCPs, patients and consumers. Developers of mHealth solutions should work with both the government and insurance companies to ensure affordable mHealth solutions can be achieved. mHealth solutions should gain HCP buy-in Evidence that mHealth solutions lead to better quality of care is seen as a key factor among HCPs and patients for increasing usage. Consumers and especially patients are looking for solutions to be recommended by their HCP. Developers should consider partnering with medical providers to help them demonstrate the benefits of mHealth and giving HCPs support when advocating specific solutions. mHealth solutions should be simple and intuitive Nearly 60% of HCPs require mHealth solutions to integrate seamlessly into their current practice, making it the most important factor for success amongst this population. Around 50% of HCPs, and 40% of patients and consumers, believe mHealth solutions should be simple and intuitive to use, and similar proportions are looking for mHealth to reduce the complexity of managing their condition / health.

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Fig.13: Factors Leading to Greater mHealth Usage by Respondent Group

HCPs Affordability Patients General Wellness Consumers 59% 55% 57%

Solutions are reasonably priced / affordable

47%

Solutions are paid for by government / reimbursed

34%

47%

HCP buy in

Recommended by my HCP Patients General Wellness Consumers Shown to improve management of condition / health Solutions are reasonably priced / affordable

46% 54% 53%

61%

HCPs

HCP buy in and Intuitive Affordability Simple

46% 47%

59% 55% 57% 59%

Solutions are paid for by government / reimbursed Can be integrated into current systems

34%

47%

Solutions simple and intuitive to use Recommended by my HCP Shown to reduce time needed to manage condition / health Shown to improve management of condition / health

47% 45% 38% 46% 46% 46%

53% 61%

51% 54% 53%

mHealth services need toifhave the flexibility to be tailored for individual patients, especially 59% I would use more mobile health solutions they could -3 70 be customised to the patients dexterity Can / literacy regarding literacy levels. This be integrated into currentincreased mHealth usage from the vast majority would lead to systems (70%) ofuse mobile health if Icurrently limit their usage due to patient suitability questions. HCPs 53% less are I would HCPs who had a specific device -10 43 rather than use my mobile phone simple and Solutions 47% convinced that the answer lies in offeringintuitive to use either specific devices or devices that connect to patients 45% I would be happy to provide my patients solution their mobile phones. Thewith a device lies in the ability to customise the offering rather than51% mode of the -40 27 to connect to their mobile phone: to manage condition / health Shown to reduce time needed 38% delivery. 46% Fig.14: Overcoming HCP Barriers to Greater Usage of mHealth: Not Suitable for All Patients
I would use more mobile health solutions if they could I would use mobile health solutions if be customised to the patients dexterity / literacy my doctor did prescribe them I would use mobile health if I had a specific device I would use mobile health solutions if I could buy them rather than use my mobile phone directly from pharmacies / other healthcare providers I would be happy to provide my patients with a device I would use mobile health solutions if I could to connect to their mobile phone: buy them directly from retailers Disagree Agree -3 -19 -10 -33 -40 -33 70 62 43 24 27 19 Simple and Intuitive

I would use mobile health solutions if my doctor did prescribe them I would use mobile health solutions if I could buy them directly from pharmacies / other healthcare providers I would use mobile health solutions if I could buy them directly from retailers Disagree Agree

-19

62

-33

24

-33

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Simple and Intuitive

Can be integrated into current systems

59%

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47% 45% 38% 53%

12

Solutions simple and intuitive to use

Shown to reduce time needed to manage condition / health

51% 46%

I would use more mobile health solutions if they could be customised to the patients dexterity / literacy

-3

70

TheI would use mobile healthofI had a specific device vast majority if patients would use mHealth if it were offered by their HCP. Patients believe -10 43 rather than use my mobile phone and trust that their HCP is the expert and as such advocacy should be built amongst HCPs. This I would be happy to advocacy canprovide mybetheir mobileaphone:to ensure the benefits are promoted to patients, who then have the then patients with device mobilised -40 27 to connect to opportunity to access mHealth. Fig.15: Overcoming Patient Barriers to Greater Usage of mHealth: Not Recommended by HCP
I would use mobile health solutions if my doctor did prescribe them I would use mobile health solutions if I could buy them directly from pharmacies / other healthcare providers I would use mobile health solutions if I could buy them directly from retailers Disagree Agree -19 62

-33

24

-33

19

Implications and Recommendations Overall, the study highlights the need for partnerships and cross-stakeholder engagement in order for HCPs, patients and consumers to derive the maximum benefits from mHealth. This will require mobile operators and solution developers, the healthcare industry and regulatory bodies / insurers to work together to create an environment in which mHealth is readily accessible and meets end users needs. In addition, the study reveals that awareness of mHealth is paramount. Although end users have a reasonable understanding of mHealth, awareness of the potential benefits and how to recognise optimal mHealth solutions for particular situations is inconsistent. There is a role for all stakeholders to play in enhancing overall knowledge of mHealth benefits and options. This study informs a number of recommendations for each stakeholder. Mobile Operators Develop simple, customisable solutions that will fit all patient types Provide a full service model, offering not only the mHealth solution but also education and technical support Promote mHealth solutions ability to meet the big challenges of behavioural change, including diet/lifestyle support and medication compliance Seek partnerships with key medical associations / patient groups to promote wider adoption of mHealth solutions Ensure mHealth solutions adopt varying price structures, including fee-for-service models

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Healthcare Industry Partner with mobile operators to tap into the expertise in designing solutions that are customisable and flexible to fit all end user groups and needs Support mobile operators in designing solutions that are interoperable with current healthcare systems Patient and Consumer Groups Patients should seek advice from their HCP on how mHealth could benefit them and which solutions might be appropriate Patient associations should lobby for mHealth to be made available by federal agencies / payers to allow maximum access Healthcare Practitioners Open the conversation with patients about mHealth and discuss whether and how it could benefit them Recommend mHealth solutions that are appropriate to individual patient circumstances Governments, Regulators and Insurers Develop awareness campaigns for mHealth with HCPs and patients Ensure mHealth solutions that deliver patient and system benefits are reimbursed Work with mobile operators to develop solutions best suited to the needs of the population

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