Kenneth Moore, Director of IEEE Book and Information Services (BIS)

‘Behold, I will bring to it health
and healing, and I will heal them and reveal to them abundance of
prosperity and security’

Jeremiah 33:6

‘Mespot,’ to the day when the palm trees will smile again

and

To the centenary of ‘Forget-Me-Not.’

Robert S. H. Istepanian

ROBERT S. H. ISTEPANIAN

Robert Istepanian is recognized as one of the leading authorities and pioneers of mobile healthcare and the first scientist to have coined and defined the concept of “m-Health.” He holds a Ph.D. in Electronic and Electrical Engineering from Loughborough University, UK, and he has held several academic and research posts in the UK and Canada. These included visiting professor at the Department of Electrical and Electronic Engineering, Imperial College, London; professor of Data Communications for Healthcare and founding Director of the Medical Information and Network Technologies Research Centre at Kingston University, London; senior lectureships in the Universities of Portsmouth and Brunel University, UK; and associate professor at Ryerson University, Toronto with adjunct professorship at the University of West Ontario, Canada. He has also held a visiting professorship at St. George's Medical School, University of London, and was the Leverhulme distinguished visiting fellow at the Centre for Global e-Health Innovation, University of Toronto.

Professor Istepanian was awarded the 2009 IEEE award for the best and most cited paper by the IEEE Engineering in Medicine and Biology Society for his seminal paper on mobile healthcare (m-Health) published in 2004. He was also the recipient of the IEE Heaviside Award in 1999 from the Institution of Electrical Engineering, UK. He has led numerous funded multidisciplinary research projects on m-Health, e-Health, and telehealth funded by the UK Engineering and Physical Research Council, the European Commission, the British Council, the Royal Society, the Royal Academy of Engineering, and the Leverhulme Trust, in addition to sponsored projects and clinical trials funded by global telecom and mobile industries.

He has served as the Vice-Chair of the International Telecommunication Union focus group on standardization of machine-to-machine (M2M) communications. He has also served as an expert on numerous assessment and peer evaluation panels on healthcare technology innovations, well-being, m-Health, and e-Health, including the Dutch–Philips partnership program on “Healthy Life Style”, the Science Foundation Ireland Strategic Research Cluster Grants program, the Finnish Strategic Centers of Science, Technology and Innovation, and the Canada Foundation for Innovation. In addition, he has been a peer reviewer for the following UK Funding bodies: EPSRC, BBSRC, Wellcome Trust, Department of Health, Service Delivery Organisation, Health Innovation Challenge Fund, National Institute of Health Research, BUPA Foundation, and Diabetes-UK. Further, he has served on the editorial board of IEEE Transactions on Information Technology in Biomedicine, IEEE Transactions on NanoBioScience, IEEE Transactions on Mobile Computing, International Journal of Telemedicine and Applications, Journal of Mobile Multimedia, and Journal of World Medical & Health Policy, and as guest editor of the first two of these journals.

Professor Istepanian has served on numerous IEEE committees and chaired organizing and technical committees of national and international conferences in the United Kingdom, the United States and elsewhere, including the Telemed Conferences at the Royal Society of Medicine, London, the IET, London, the 2000 World Medical Congress, Chicago, and the successive IEEE Engineering in Medicine and Biology International Annual Conferences. He has been invited to present numerous keynote lectures at international conferences and meetings in the UK, Europe, the US, Canada, and other countries. His publications exceed 200 peer-reviewed papers and books on mobile communications for healthcare, m-Health, control systems, and biomedical signal processing.

BRYAN WOODWARD

Bryan Woodward holds two UK doctorates, a Ph.D. in physics from the University of London (Imperial College) and a D.Sc. in electronic engineering from Loughborough University. He has held positions with the UK Atomic Energy Authority, the Royal Australian Navy, Guy's Hospital Medical School, the Australian Atomic Energy Commission, and Loughborough University, where he was Head of the Department of Electronic and Electrical Engineering and a professor with the department's Centre for Mobile Communications Research.

Professor Woodward has been an external examiner for higher degrees at universities in the United Kingdom, France, India, and Australia; a referee for professorial appointments at 12 universities; an invited lecturer in Australia, Burma, China, India, France, Poland, and the United Kingdom; and an expert assessor for peer review research panels for the Australian, Canadian, and Spanish governments, for the UK Engineering and Physical Sciences Research Council (EPSRC), and for the European Commission's 5th and 6th Framework Programmes. Furthermore, he has been a chief examiner and moderator for the UK Engineering Council examinations and a consultant to over 20 companies. He has published over 60 academic journal papers and 120 international conference papers, as well as many articles for professional and popular magazines, and he has also done over 30 radio interviews. Finally, he has been a publications referee and book reviewer for Electronics Letters; IEEE Communications Magazine; IEEE Journal of Information Technology in Biomedicine (as Associate Editor and editorial board member); International Journal of Electronic Healthcare; International Journal of Telemedicine and Applications; Journal of Mobile Multimedia; Medical Engineering and Physics; Optics and Lasers in Engineering; Proceedings of the IEE (Circuits, Devices and Systems); Proceedings of the IEE (Communications); and Ultrasonics.

Professor Woodward has participated in or led 10 multinational research projects funded by the European Commission and others funded by the EPSRC, the UK Department of the Environment, the Indian Department of Science and Technology, and industrial companies. He has also co-ordinated a major m-Health project funded by the British Council's UK–India Education and Research Initiative (UKIERI), with the aim of using mobile communications to improve the monitoring of heart disease and diabetes, which are prevalent in both developed and developing countries. The UK partners were Loughborough University and Kingston University; while the Indian partners were the Indian Institute of Technology Delhi, the All-India Institute of Medical Sciences, and Aligarh Muslim University.

Having retired, Bryan Woodward is now an Emeritus Professor of Loughborough University.

The prominence of mobile health technologies as a driver for national and international healthcare strategies will undoubtedly grow as modern medicine advances into the 21^st century. With smartphone penetration nearly ubiquitous in both the developed and developing world, the global potential to enable high-quality, cost-effective healthcare services - and meaningful patient engagement with patients and the public - is enormous. However, there are unique challenges in tailoring these m-Health strategies to make them accessible in the developing world and to an ageing population burdened with chronic disease. We must also address the important issues of public trust in data sharing, security, consent and privacy that will enable the profound benefits of digital, connected healthcare systems or, which, as likely, could inhibit progress if not tackled head-on.

m-Health: Fundamentals and Applications is a wonderfully comprehensive introduction to the subject of m-Health with valuable examples of studies and successful applications of this rapidly emerging innovation in healthcare. It highlights the crucial work that needs doing if we are to close the gap between what we know—in terms of the clinical evidence supporting m-Health innovation—and the challenges of consumer acceptability that may prevent wider adoption and diffusion of this exciting technological platform.

Professor the Lord Ara Darzi of Denham OM KBE PC FRS

Director, Institute of Global Health Innovation, Imperial College London

Mobile health (m-Health): Is it one of the greatest technological breakthroughs of our time or just another much-hyped smart healthcare technology bubble that could burst soon? Such a paradoxical view is perhaps an accurate reflection of the current status of m-Health. This important, if not essential, healthcare technology is known today to millions of people, both medical and nonexpert alike, as a powerful and transformative concept much needed for twenty-first century healthcare services.

This book has been written to continue the story of m-Health and its development since 2003. Over a decade ago, when m-Health was first introduced and defined, there was no indication then that it would be transformed into today's global multibillion dollar industry, albeit viewed critically and cautiously by the medical and healthcare communities.

M-Health was first defined as mobile computing, medical sensor, and communications technologies for health care. This simple yet powerful interpretation of m-Health as a scientific and technological concept has been driven to successful implementation by enthusiastic stakeholders and by rapid developments of these three enabling pillars. Unsustainable healthcare costs and ever-increasing demands for better access and quality of care make m-Health an important technology concept. Unfortunately, m-Health has been distorted and undermined by misleading interpretations, leading to the current spectrum of contradictions and paradoxical views. The collision of the end objectives, requirements, and evidence from opposing business and medical targets is fuelling this status quo and inhibiting the as yet unseen potential of m-Health. As an example of this scenario, we all see today major industrial power houses from global telecom, mobile phone, pharmaceutical, health, and insurance companies, and other health-related industries, all vigorously advocating different “consumer m-Health” products and services in a variety of standards and formats. They range from smart consumer well-being trackers and health monitors, smart health watches, and various targeted healthcare and mobile disease management tools. These and other consumer-based m-Health monitoring devices are becoming increasingly popular and widely used in spite of the absence of large-scale clinical evidence of their healthcare outcomes and improved patient care. The proponents of this consumer's face of m-Health argue that this represents the best realistic path for future predictive healthcare and well-being, and that it potentially alleviates the current burdens of the symptomatic healthcare costs.

At the opposite end of the spectrum, we witness an increasing level of interest in the academic and medical research communities, which target cutting-edge research conducted in different areas of mobile healthcare, leading to many publications, reports, and articles that reflect the clinical outcomes of these studies. Mobile health is also being increasingly taught in related medical and health information training courses. However, regardless of the clinical outcomes of m-Health, there is an increasing trend by some healthcare providers to voice a cautionary note concerning the hype of m-Health, with nonconviction as to the real benefits, questioning its clinical effectiveness and efficacy. These are increasingly justified by the lack of global evidence of large-scale endorsements and acceptance of m-Health by healthcare providers and services. This picture, however, detracts from the clear global health benefits of m-Health.

Increasingly, experts and nonexperts alike are also confused by the plethora of alternative terms and abbreviations being used, such as connected health, smart health, and even digital health, which perhaps reflect this conundrum. These terms are being increasingly used to either replace or justify a new beginning or even shy away from m-Health for one reason or another. Perhaps these newer terms might also reflect the answer to the key question that everyone has been asking for years: Is m-Health dead or has it just moved address?

The answer clearly lies in the powerful market forces and economic benefits already mentioned, in addition to the daily supplement of hundreds of m-Health-related documents published in research and NGO reports, academic papers, books, market analysis documents, and online blogs and articles, as well as annual conferences and summits organized globally, reflecting a decade-long evolution of this healthcare technology concept.

Consideration for brevity and the desire to avoid wearying the well-informed by cataloguing what they will regard as obvious has led us to omit from these pages lengthy explanations of certain broad technical issues as much as possible. These issues might be unknown to that large group of general readers who look perplexed when the name “m-Health” arises in conversations, and who only brighten up when it is explained to them that in its most simplistic form it is the use of smartphones for healthcare! This book may, however, serve to bring before the wider spectrum of interested readers some clarification of such a “black hole” and outline something of the infinite variety of the concept. Furthermore, we hope that it will help both expert and lay readers to understand the complexity of m-Health. For this reason we have omitted mathematical equations from the text, but have referenced more detailed papers and books where appropriate.

Chapter 1 charts the evolution of m-Health more than a decade ago and how it was transformed from a mere academic concept to a global, albeit controversial, healthcare technology phenomenon.

Chapters 2–4 describe in detail the basics of the three enabling scientific technological elements of m-Health (sensors, computing, and communications). We describe how each of these key ingredients has evolved and matured over the last decade. We describe, for example, the rapid evolution of m-Health in parallel with the maturing process of its enabling technologies from biowearable sensors to the wireless and mobile communication technologies of 4G and 5G systems and beyond. We also detail in these chapters the impact of new computing and Internet paradigms from the Internet of things (IoT) to Web 2.0 and Health 2.0 on m-Health. We also discuss the role of the current m-Health Apps phenomenon and their clinical efficacy and design challenges, together with other issues such as the role of social networking and healthy data mining concepts on the future advances of “m-Health 2.0.”

Chapter 5 illustrates some of the relevant medical aspects and clinical applications of m-Health. We endeavor to clarify some of the concerns and varying views that are being discussed and advocated by the medical community, particularly on the clinical efficacies and effectiveness of some of these smartphone-centric m-Health interventions and applications. These applications are supplemented by clinical examples and current studies, particularly in acute and chronic disease management, and in other important medical conditions. The studies provide clear clinical outcomes in some areas as well as ambiguous and unclear evidence in others.

Chapter 6 presents one of the most rewarding and successful areas of m-Health, which is the endorsement of the success of mobile health as a global health phenomenon. In this chapter, we describe successful applications and deployments of m-Health in various global health settings, particularly in developing countries. We also describe some examples of m-Health in postconflict regions in the world. These examples represent ample proof of the success of m-Health as a transformative concept for better and more effective healthcare delivery, especially in those areas where it is most needed, and where its clinical evidence is clear and its economic impact is justified.

Chapter 7 discusses m-Health markets, business and ecosystem models, and policy-related issues. This illustrates how consumer-led “m-Health” markets are, and will continue to be, one of the driving forces behind the global proliferation of m-Health markets, especially in specific areas of wellness and health monitoring, regardless of the healthcare outcomes and medical efficacy objectives and the pros and cons of markets.

In the last chapter, Chapter 8, we discuss the future of m-Health and we present a vision for its future direction and how this concept can potentially shape and transform healthcare services in the coming decades of the twenty-first century.

Finally, although it is not an easy task to write a book on m-Health and at the same time cover all the important aspects in one volume, we have attempted to include the most relevant issues. This book is mainly written to increase the general awareness and importance of m-Health, not only to interested stakeholders, such as clinicians, healthcare providers, patients, consumers, telecommunications and mobile phone industries, and health insurers, but also to interested lay readers. The aim is to describe the initial philosophy of m-Health, its evolution, and current state of the art, where it is heading and, most importantly, how it can transform some the current healthcare services to better, more efficient, and affordable means of personalized care delivery.

Robert S.H. Istepanian
London, UK

Bryan Woodward
Loughborough, UK

The authors would like to express their deep gratitude to Lord Darzi of Denham of Imperial College London for his very gracious and generous foreword for this book.

Robert S. H. Istepanian would like to acknowledge the support of the late Professor Swamy Laxminarayan, founding Editor-in-Chief of IEEE Transactions on Information Technology in Biomedicine (now IEEE Journal of Biomedical and Health Informatics), for his vision and leadership in publishing one of the first papers on m-Health in the Transactions.

He would also like to thank all his clinical, academic, and industrial colleagues with whom he collaborated over the last two decades. Special thanks are due to Jose Lacal (Stryker MAKO), Kunle Ibidun (formerly with Orange, France Telecom), Yuan Ting Zhang (Chinese University of Hong Kong), Emil Jovanov (University of Alabama, Huntsville, AL), Costas Pattichis (University of Cyprus), Aura Ganz (University of Massachusetts, Amherst, MA), Nada Philip, Ala Sungoor, Bee Tang, and Barbara Pierscionek (Kingston University, London, UK), Nazar Amso and John Gregory (Cardiff University Medical School, UK), Ken Earle (St. George's Medical School and NHS Trust, London, UK), Tony Constantinides (Imperial College, London, UK), Garik Markarian (Lancaster University, UK), Adel Sharif (Surrey University, UK), Hamed Al-Raweshidy (Brunel University, UK), Alex Jadad, Joseph Cafazo, and Tony Easty (Centre of Global e-Health Innovations, University of Toronto, Ontario), Kaamran Raahemifar (Ryerson University, Toronto, Ontario), and others I may have inadvertently omitted.

Special Acknowledgement: To Bryan, what can I say? Fate brought us together one autumn day in October 1990 when I stood for the first time at your office door at Loughborough University as your new Ph.D. student. Perhaps now you wish you had the Star Trek “Tricoder” to “energize” me away to another Galaxy! Many thanks for your wonderful friendship and English sense of humor, and most of all for all the years of support that I will not forget.

Bryan Woodward would like to thank former colleagues, research students, and final-year students of the Department of Electronic and Electrical Engineering at Loughborough University, particularly David Mulvaney, Sekharjit Datta, Paul Harvey, Omar Farooq (now with Aligarh Muslim University, India), Fadlee Rasid (now with University of Putra Malaysia, Malaysia), Anoop Vyas (now with Indian Institute of Technology Delhi, India), and Bhaskar Thakkar (now with G H Patel College of Engineering and Technology, Gujarat, India).

Special Acknowledgement: My 40-year career at Imperial College London, Guy's Hospital Medical School, the Australian Atomic Energy Commission, and Loughborough University would never have come to fruition but for my good fortune to have met a great teacher when I was 15 years old. The most influential person in my life was the late Harry Morgan, who taught me the power and beauty of the English language and whose inspirational teaching during a difficult period I will remember all my life.

Most of the contracts and grants for our research on m-Health has been awarded by the Engineering and Physical Sciences Research Council, the European Commission's IST, FP7 and Marie Curie Programmes, industrial sponsorships (Motorola USA, Orange, and France Telecom), The Leverhulme Trust, The Royal Society, The Royal Academy of Engineering, The British Council's United Kingdom–India Education and Research Initiative, and the Indian Department of Science and Technology.

We are also particularly indebted to Mr. Harry Istepanian for his excellent work and support in preparing all the graphics and figures in the book, with the assistance of Mr. Dilip Romesh Aravinda (figures graphic design) and Ms. Barbara Lauger (proof reading).

Many thanks are also due to Ms. Mary Hatcher at John Wiley-IEEE Press for offering us the opportunity to publish this work and also for her patience during the much delayed writing process. We would also like to thank Mr. Brady A. Chin at John Wiley-IEEE Press, Danielle Lacourciere (Wiley) and Shikha Pahuja (Thomson Digital) for their editorial assistance in the final preparation of this book.

Finally, we acknowledge our families for their unfailing support and encouragement during the years, and their unrecorded kindness that has rendered our work less difficult.

Units