Just because we have apps for smartphones doesn’t mean we have real mobility in healthcare

December 21, 2012

App47 CEO and co-founder Chris Schroeder hosts a great podcast series called “What’s Appening!” in which he covers topics around enterprise-grade Mobile Application Management for securely deploying, managing, and analyzing business-critical mobile apps. Chris interviewed me for a recent episode in which we spoke at length about the management of enterprise healthcare apps, what mobility means in healthcare, and why technically-savvy clinicians are the only real salvation for the healthcare IT industry. The audio version of the podcast is available on the App47 site and is summarized below. 

Chris: Healthcare IT is seen to be continuously growing and gaining momentum in the deployment of mobile apps for enterprise use. How do you see healthcare IT taking advantage of mobile applications?

Shahid: Yes, you are absolutely right.  There are a whole lot of events going on in healthcare IT, especially related to mobile.  The majority of mobile apps that are out there today are more along the lines of informational content. For example, information on how to do more exercise, what you should do about diabetes etc. In those cases, it doesn’t really matter how enterprise mobility is handled because they are literally consumer directed and informational just like any other informational website.

However, there are two other big categories of health IT- based apps, especially the applications moving into the medical device arena. These are diagnostic applications and therapeutic applications. Example of a diagnostic application would be an app that takes a picture of a mole on your hand and gives a diagnosis of whether it is more than what it looks like.  Workflow-based applications are where actual therapy is administered. So on one side; you have one big block of educational and informational content, where very little enterprise management of mobile apps really matters and on the other side, you have diagnostic and therapy based applications where everything that you refer to around an enterprise, such as security and manageability, starts to matter a whole lot.

What’s happening in the diagnostic and therapeutic space is that today’s mobile app developers don’t really know whether their apps are therapeutic, diagnostic or content-based. They don’t know if they would need to make the apps trackable or the kind of testing that would need to be applied on these apps. They are also uncertain as to what kind of security would need to be applied or how authentication would need to be done across multiple applications. All these kinds of concerns and issues are obviously the ones that App47 is going to help healthcare companies solve and manage better.

In the current space, there is confusion between what is mobile, like what is a mobile application and what does mobility in healthcare really mean. They are really not the same thing. They sound like they are very similar. Having a mobile app strategy now would be like having a “laptop app strategy” 10 years ago. Having had a laptop app strategy 10 years ago would seem just as silly. In the same manner, having a pure mobile app strategy would seem pretty silly 5 or 10 years from now.

The mobile space should be viewed in totality and thought about how it would ideally fit into the enterprise. If you can seamlessly move a workflow from a desktop app to a web app into a mobile app to a remote medical device, that’s mobility. Creating an app that runs on a smartphone is not mobility of workflow, it’s just an app. Say, a doctor is looking at a patient in an electronic healthcare record, and say the doctor is asking the patient to use a particular diagnostic or therapeutic or content based application.  There needs to be someone who needs to know which doctor had prescribed a particular therapeutic or diagnostic app (just like a drug or a device prescription) to a patient. The prescribed app’s authenticity needs to also be verified. Someone needs to check if the app has indeed been launched, has been sandboxed, has been used extensively or if any privacy data has been locally stored so that it may pose a risk if the device is lost.

Viewing healthcare mobility in its entirety and looking at how different workflows are used on different devices would let you fit the mobile apps appropriately for that particular enterprise. This view is what I believe is truly missing in the healthcare IT industry, especially where related to mobile. We’re so enamored by smartphones and simple apps that we think there’s actual value in any particular app more so than in the total mobility of the workflows themselves.

Chris:      That’s interesting. When we talked to more of the system integrators around healthcare IT, it seemed that for the practitioners of electronic healthcare record systems, “going mobile” meant using a Citrix Receiver to remote desktop into a Windows machine that actually gained access into the electronic healthcare record’s system. As the data was all streamed to the device and since no data was ever actually on the mobile device, they’d have the ultimate security even though this methodology lacked on the usability side. Are you starting to see the companies wanting to match the user experience with the data privacy which would drive a more richer experience or do you think this is even further in terms of timeline?

Shahid:   Yeah, I unfortunately believe it’s further off in terms of timeline, because the kinds of smart companies that you just asked about don’t really exist today in the way that you’re talking about. Here’s why. Most people who give you the “excuse” or explanation that they’re using Citrix for security are not actually telling the whole truth, because in most cases they’re using Citrix and other techniques because they can’t support real mobility. They can support moving their screens from a PC onto a tablet through Citrix or Terminal Services, and they tell you that because that’s all they know how to support. They know it’s not the right thing to do but can’t easily admit it.

They know, for example, that an iPhone or an Android, which has email on it, does not look like Microsoft Outlook. Imagine that vendors who gave you email on your mobile device gave you the same story that they couldn’t possibly put email on these devices because they were not secure enough. It would be an insane statement. The only reason we accept it in healthcare is because we have no choice and many customers don’t know better.

We need more companies that understand mobility of workflows (not just how to write apps). When you think about email that is a truly mobile experience, what do you need? Consider that you are working on your desktop. At that point, email has complete functionality. When you move to a web application, you lose a bit of the functionality and when you move to a simplified web experience, you lose it a little bit more. However, the essence of the capabilities and the user experience is still there. Going to mobile versus tablet, with the small screen space and the big screen spaces, the email client corporations and companies that make these do a good job of understanding what individuals need when they are walking, running or sitting at a computer.

Most of the electronic health vendors out there, about 600 plus of them, do not understand what the individual mobility needs are and even if they did, they do not have personnel who could do something about real mobility (versus tossing together some simple smartphone apps) at this time.

However, companies like yourself that are in this space explaining to people that a mobile app does not make mobility and clarifying that an enterprise solution allows you to break off certain workflows and change user experiences depending on what kind of devices you’re launching, is what makes all the difference in the world.

Right now, it is a problem that some infrastructure tools don’t exist. It is sometimes a user experience problem that people just don’t get the fact that a mobile app doesn’t mean that the screen on the desktop shows up on an iPad or mobile. It’s really a lack of understanding and a lack of knowledge. I wish more companies would do exactly what you are asking for, but it may take us a little while because of the user design and experience capabilities that are required.

Chris: In every bit of technology that I’ve ever been involved in, there have been times when we sat down and thought of a technology solution. In this case, mobile app and native mobile app immersive experience makes absolute sense. Who do you think is going to drive this so that we have a  better, more intuitive, more immersive, more real time and easier user experience but still have the security? Would it be the practitioner that’s going to drive that? Would it be the EHR systems that are implementing these capabilities or somebody else? Who do you think would be going to help drive that from a demand perspective to produce a market that’s worth going after?

Shahid:   Yeah, terrific question. It would be nice for the EHR vendors to do this because they know the workflows pretty well from a purely technical point of view. We, in the industry, need to start to understand that healthcare is so big and so important that it cannot be left to the healthcare IT industry to solve. I say this, being both in the government as well as in health IT and combined with the medical device space. What folks do in health IT and in the medical device industry is pretty good for those particular areas which I call “retrospective document management” or managing patient records, etc. as opposed to actually enhancing and managing care.

If we are going to view it from the perspective of making sure that everything that is done to a patient is tracked and recorded so that the patient or their insurance company can be billed for it, then that would be a traditional IT company’s view. Electronic Health Record (EHR) or Electronic Medical Record (EMR) companies are focused on documentation for tracking bills and record management. However, if we are going to view it from the perspective of improving the care of patients, improving the actual outcomes of healthcare in general for our patients, then that would have to be in the hands of the clinicians.

Unfortunately, most of us as technologists don’t understand clinicians’ jobs very well. We end up giving clinical providers what we believe is a solution to their problem based on our understanding. We make a web application or a mobile application of some sort and give it to them telling that this is the solution to your problem. In reality, we are giving them a monolithic application which doesn’t understand their actual workflows. It is just like, we, as programmers, never want one giant application solution given to us to use. We like things that are small and nimble and easy for us to adapt and put to different uses than initially intended by designers. We like simple things put together to solve our problems. That is a traditional technique that we programmers have used for time immemorial. That is just the way that we work, it was the way UNIX was created, and it is the way that programmers do things. We create little snippets of code, we take another snippets that someone else has written, and tie them together. That kind of approach is what is sorely lacking in the healthcare space because it’s very permissions-oriented. Clinicians, especial nurses that have some of the hardest jobs, have to get permission before doing new things with technology.

In the end, the answer to your question is very, very simple. The only people that will create actual solutions to healthcare outcomes problems are going to be clinicians because that’s their job. Our job, in the technical industry is to create the proper tools, techniques, infrastructure, and these design surfaces where they don’t have to pick up monolithic things and use them but instead, have portions of monolithic things that they can put together and go forward on.

What I am saying would sound completely insane for someone who has been in clinical practice for 50 years and is about to retire. He would never want to go through any of the latest technology stuff or mobile applications since he is about to retire.

I am actually talking about the residents, the students and the folks that have been in the industry for probably less than 10 years. They think just like we do in any technical community. They don’t think in terms of monolithic anything. They think in terms of these small easy to assemble components and that is unfortunately not the way the health IT world works today.

Summarizing the answer to your question, if you’re looking at retrospective documentation to store what happened about a patient in the past, that is a terrific thing to leave to the existing firms but new firms must be created to do everything else. In fact as an angel investor and an entrepreneur, most of my thinking these days is around how do we fund and build these companies that can help create small reusable components that we can put together and put them in the hands of development friendly or script friendly clinicians?  Only they know their job and their job changes during the day enough that no monolithic apps we give them, monolithic will work for all situations.

Chris: That’s awesome. Shahid. I think it has been a great insight to healthcare IT, where we’re at and hopefully painting a bit of a picture of where we’re going. I think there are a lot of exciting times ahead for healthcare IT, and opportunity probably most importantly in what we’re doing. Thank you for your time today and we really appreciate it.

Shahid:   Sure. I appreciate you having me, and just remember, everybody in the tech world keep in mind what I just said. Healthcare and the technology associated with healthcare are so important that can’t leave it to just “health IT experts.”  They haven’t gotten us far enough in the last 25-30 years and they can use your help. I’ve been in this industry for a long time and have never been more excited about the opportunities. This is a perfect time for anybody who’s created cool things in other industries to jump in and start providing solutions for this very important industry.

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  • Jerrmi

    Shahid is an internationally recognized enterprise software analyst that specializes inhealthcare IT with an emphasis on e-health, EHR/EMR, Meaningful Use.

  • Sbercollege

    It’s the time of year that many writers reflect on the major events of the past 365 days. I’ll let the journalists cover the impact of the election, the epidemic of senseless violence, and the scandals of infidelity.

  • MarkjewellMD

    If you can seamlessly move a workflow from a desktop app to a webapp into a mobile app to a remote medical device, that’s mobility.

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