Mobile Health (m-Health) in Retrospect: The Known Unknowns

25 de março de 2022

69 minute read

MDPI
Robert S. H. Istepanian
Institute of Global Health Innovation, Imperial College London
22 March 2022

EXCERPT VERSION

by Joaquim Cardoso MSc.
Chief Editor of “The Health Revolution” Institute @ Mobile Health
March 25, 2022

This is an excerpted version of the publication above, focusing on: (a) Introduction; (b) Definition; (c) Discussion and (d) Conclusion.
For the full version of this paper, please, refer to the 2nd part of this post.

Abstract

For nearly two decades, mobile health or (m-Health) was hailed as the most innovative and enabling area for the digital transformation of healthcare globally.

However, this profound vision became a fleeting view since the inception and domination of smart phones, and the reorientation of the concept towards the exclusivity of global smart phone application markets and services.

The global consumerization of m-Health in numerous disciplines of healthcare, fitness and wellness areas is unprecedented.

However, this divergence between ‘mobile health capitalism’ and the ‘science of mobile health’ led to the creation of the ‘m-Health schism’. This schism was sustained by the continued domination of the former on the expense of the latter.

This also led to increased global m-Health inequality and divide between the much-perceived health and patient benefits and the markets of m-Health. This divergence was more evident in low and middle income (LMIC) countries compared to the developed world.

This powerful yet misguided evolution of the m-Health was driven essentially by complex factors. These are presented in this paper as the ‘known unknowns’ or ‘the obvious but sanctioned facts’ of m-Health.

These issues had surreptitiously contributed to this reorientation and the widening schism of m-Health.

The collateral damage of this process was the increased shift towards understanding ‘digital health’ as a conjecture term associated with mobile health.

However, to date, no clear or scientific views are discussed or analyzed on the actual differences and correlation aspects between digital and mobile health.

This particular ‘known unknown’ is presented in detail in order to provide a rapprochement framework of this correlation and valid presentations between the two areas.

The framework correlates digital health with the other standard ICT for the healthcare domains of telemedicine, telehealth and e-health. These are also increasingly used in conjunction with digital health, without clear distinctions between these terms and digital health.

These critical issues have become timelier and more important to discuss and present, particularly after the world has been caught off guard by the COVID-19 pandemic.

The much hyped and the profiteering digital health solutions developed in response of this pandemic provided a modest impact, and the benefits were mostly inadequate in mitigating the massive health, human, and economic impact of this pandemic.
This largely commercial reorientation of mobile health was unable not only to predict the severity of the pandemic, but also unable to provide adequate digital tools or effective pre-emptive digital epidemiological shielding and guarding mechanisms against this devastating pandemic.

There are many lessons to be learnt from the COVID-19 pandemic from the mobile and digital health perspectives, and lessons must be learnt from the past and to address the critical aspects discussed in this paper for better understanding of mobile health and effective tackling of future global healthcare challenges.

1. Introduction

What is mobile health or (m-Health)? For nearly two decades, this important question has been the subject of numerous debates, discussions, speculative analysis and studies.

Many of these brought either incomplete, vague or even erroneous answers to this key question.

The premise of most of these answers were based on the interpretation and the understanding that mobile health is an adjunct concept associated with the technological and computing traits of smart phones to enable healthcare connectivity and improved delivery services.

These powerful traits of the smart phones were utilized effectively and widely via numerous tools and solutions centered on the smart phone health applications (Apps) and their connectivity ecosystems.

These largely commercial systems were successfully applied in all shapes and formats to many healthcare, diagnostics, monitoring, wellness, social, and behavioral healthcare domains.

Yet, this narrow yet popular interpretation of mobile health is foremost based on the consumerization and the monetization opportunities offered by smart phones in all these areas.

However, this m-Health reorientation from the post smart phone era is entirely incompatible with the basic scientific principles of mobile health as were originally envisioned.

In order to provide a more succinct and scientific answer to the above question, it is important to understand that the drivers for this reorientation are the ‘known unknowns’ associated with the origin and evolution of mobile health.

These were not appropriately or widely understood or disseminated.

The reorientation of mobile health towards the singular smart phone centric format was the result of the ignorance of the origin of mobile health, whether deliberate or not, which was initially carried out systematically and meticulously by the leading global corporate telecommunication and IT conglomerates who have shown an early interest in this area, and identified the massive potentials for their markets and businesses first and foremost.

For more than a decade, numerous m-Health systems centered on smart phone applications were applied to a large volume of clinical studies and evidence-based studies conducted globally.

In many of these studies (with few exceptions in some applications), the clinical and economic end results proved to be either limited or with no tangible difference. These included, for example, the lack of rigorous evidence on the efficacy, efficiency, cost, global outreach, patient acceptability, privacy, security and many other challenges. These remain largely under the cliché of ‘further research and evidence is required’. Yet, no real alternatives to these systems were presented or proposed.

This is because of the powerful and well-established global markets and penetration established by smart phone m-Health applications.

From the developing world perspective, and although the proliferation of smart phones and usage of mobile technologies is extensive in these countries, the much hyped benefits of these m-Health systems and their market-driven applications aimed to address the many healthcare challenges in the world’s poorest regions, such as improvement in health inequality, literacy, bridging the care gaps and many other challenges, remain largely modest and unattainable.

The recent COVID-19 pandemic with its devastating public health, human, social and economic impact exposed many limitations of the so-called ‘transformative’ capabilities of the ‘digital health’ applications developed in the wake of this pandemic.

Most of these recently retitled m-health applications were developed in response of the pandemic. None of these was thought or implemented prior the pandemic to provide the necessary preemptive digital global shielding or appropriate smart guarding mechanisms against its eventual wider spread with all its human, health and economic consequences.

Many of these pandemic era apps and the solutions proposed were permeated around the smart phone market models.

Most of these were based on the intrusive contact tracing, symptom detection, early diagnostics, and other pandemic responsive applications.

However, with the few exceptions of the mandatory imposed COVID-19 digital contact tracing apps and vaccination passport applications, the majority of these were either unpopular or not widely applicable or practically effective.

Furthermore, the many security and privacy issues of these applications still remain a major debatable concern and threat to the data privacy of the users in the midst of this continuing pandemic.

Nevertheless, some of these market-driven m-health applications provided some tangible clinical benefits and evidence-based impact within the clinical and wellness areas, but mostly within selected patient populations and care settings.

Structure of the paper

In order to understand these complex issues, this paper is structured into the following sections.

In the next section, the answer to the key question of ‘what is mobile health or (m-Health)?’ is presented and clarified from both a historical and a literature evidence-based perspectives. It presents the beginnings of mobile health and the core technological and scientific pillars of m-Health. This origin, together with the key milestones associated with its evolution, are also discussed.

These also present the key developments leading to the creation of the m-Health schism established after the introduction of the first generation of smart phones in 2007.

A critical view and analysis on the contradictions associated with this beginning, and the original definition together with an analysis of the subsequent definitions widely cited since then, are also presented.

The validity of these definitions from the historical, taxonomical and ontological perspectives are discussed. These contradictions contributed to the eventual reorientation of mobile health.

The third section presents a detailed analysis on the role of WHO in these definitions and the different classifications of mobile health (m-Health). It highlights the relevant shortcomings and contradictions embedded in these definitions and classifications. It questions their validity, and the methodologies used in these classifications of m-Health, and also arguing the questionable assumption of the inclusion of m-Health as part of e-health.

In Section 4, the rapprochement between mobile health and digital health are clarified and presented.

The case for the frequent and interchangeable usage of these two terms is discussed. The unclear distinction and the ambiguous understanding on the differences between the two terms, especially from a smart phone centric perspective, are analyzed. Furthermore, different representations of digital health and its correlation with m-Health and the other standard information communication technologies (ICT) for the healthcare domains are also presented to clarify the issues outlined above.

The issues presented in this analysis warrant radical rethinking of the global understanding and the future outlook on mobile health, and how it can be better understood from a scientific rather than an exclusive market view.

These critical views, if continued to be neglected, will lead to further mobile/digital health inequality, missed opportunities of global transformative healthcare benefits, and more market-driven reorientations associated with misguided benefits and limited outcomes to patients and users alike.

The next section presents a critical perspective on the key drivers of the mobile health reorientation. It presents the case of the most influential stakeholders that have impacted on this reorientation. Those are likely to impose the same influence on digital health as it evolves, and mostly likely to reshape or reorient the future of this area as well.

The final section discusses the different factors that swayed the scientific progress of mobile health to date, leading to the current and uncertain status quo.

The paper concludes with some important suggestions that advocate for the radical rethinking of mobile health based on and guided by the science of m-health, and preferably, but not exclusively, outside the existing smart phone sphere of influence.

If this vision is allowed to prevail and is better understood, especially by the global health policymakers and health institutions, scientists, and other interested stakeholders, it can, and only then, radically reverse the status quo of mobile health.

These can ultimately create vast opportunities of change towards more affordable, viable and clinically effective m-health systems for all and not for the few. It is only then that the truly transformative traits of m-health can be translated to the more effective and globally impactful outcomes of the current and future global healthcare challenges.

2. What Is Mobile Health (m-Health) in a Nutshell?

To answer this question, it is best, first, to understand the basic DNA of mobile health (m-Health).

This can be scientifically explained by revisiting the imperative notes that set the motion to establish the original concept and its subsequent definition [ 1, 2]. The principal pillars of m-Health are shown in Figure 1.

Figure 1. The basic pillars of mobile health (m-Health) (Adapted with permission from Istepanian et al. ([1,3]).

These pillars were formulated and embedded in the first definition of mobile health: ‘mobile computing, medical sensor and communications technologies for healthcare’ [ 2, 3]. This definition remains the acceptable notion and the cornerstone in understanding the concept of mobile health.

These pillars underpin the scientific and technological principles of computing, communications and sensing technologies applied for healthcare that encapsulate these basics. The details of these and other imperative notes are described elsewhere [ 1, 2, 4].

These pillars underpin the scientific and technological principles of computing, communications and sensing technologies applied for healthcare that encapsulate these basics.

Some of the ‘m’s widely attributed to m-Health include:

Mobility: The mobility aspects of m-Health are characterized with the utilization of the various modalities of mobility that aimed to improve healthcare access, increased efficiency, and potential cost reductions. However, these were largely applied within the context of m-Health smart phone applications.

Monetary and Markets: Mobile health created unprecedented markets and business ecosystems on a global scale. These largely comprise the digital innovations linked to the numerous smart phone mobile health application systems and services, and utilized for a wide spectrum of healthcare and wellness markets.

Medical evidence: Large-scale medical and clinical evidence of m-Health applications and interventions remain largely scrutinized and under the radar. Although some of these applications proved clinically effective and beneficial, many others still remain debatable with no clear evidence.

2.1. The Evolution of m-Health and the Key Milestones: Progress and Reorientaion

The fundamental principles of m-Health as described above were radically reoriented in the post smart phone era, and mark the current modus operandi of mobile health as it has been widely understood since then. The introduction of the smart phone centric mobile health applications and the market ecosystem that followed this reorientation undermined the basic scientific and technological principles presented earlier. These not only refocused the above principles through the prism of smart phone technologies and tools, but also diverted, in a globally successful way, the concept towards market priorities by encapsulating these principles within the smart phone applications (apps) domain or sphere of functions. Consequently, this reorientation process was hyped by the much-promised global transformation, outreach and improved healthcare delivery priorities of these mobile health systems.

Figure 2 shows the timeline of the evolution of mobile health since 2003. It highlights the timings of the first definition and the relevant scientific and the technological milestones and developments that impacted its evolution since 2007 [ 1]. The importance of these milestones in this context are described elsewhere [ 1].

Figure 2. The evolution and key milestones of mobile health (2003–2021). (Adapted with permission from [1] 2017 Hoboken, NJ, USA: John Wiley & Sons).

As shown, the most impactful of these was the introduction of the smart phone (iPhone) in 2007. This technological breakthrough ushered in a new, yet controversial, era for m-Health, and consequently created the ‘mobile health schism’ with two distinct, but asymmetrical axes [ 1]:

(i) The ‘market driven m-Health’ or the smart phone centric models and ecosystems.

(ii) The ‘science of m-Health’ as presented in the original core principles outlined earlier.

Whilst the success of the former is driven by the massive global markets created as a result of the unprecedented proliferation of smart phone m-Health applications (apps), the latter remained less understood or widely discussed [ 1]. It is because of this schism that mobile health was and remains widely interpreted by the former axis. This interpretation became increasingly tangled by the increasing and controversial clinical debates, supported by numerous studies that questioned whether these m-Health apps can deliver many of the much-hyped transformative and advocated outcomes and promised benefits. The COVID-19 pandemic proved the validity of this view and analysis, especially on the inability of these systems to effectively predict, respond to and mitigate global public health and catastrophic emergency situations. However, there are some valid arguments on the evidence base, clinical and economic benefits provided by some of these m-Health applications, but only in specific healthcare, wellness and patient care settings [ 1, 5, 6, 7] The global scaling-up associated with robust clinical and economic evidence on a wider scale, and the sustainability of their usage, are yet to been proven [ 8].

As shown in Figure 2, the second decade has seen continued reorientations towards the further expansion of the m-Health application ecosystems, with less attention paid to the core scientific, clinical, economic, security, privacy and other critical aspects. Over the last decade, hundreds of thousands of these mobile health applications (m-Health apps) have been developed and introduced annually. These range from applications developed by small-to-medium enterprises to globally marketed systems developed by giant high-tech and IT and pharmaceutical conglomerates [ 7]. The most successful of these applications were largely sustained by the massive injections of capital investments, corporate support, and rigorous marketing strategies. These efforts eventually paid off, creating globally successful m-health powerhouses from leading stakeholders behind these developments. However, strong evidence is yet to be seen on the scaling-up of these applications, especially in the developing world and poorer regions that face many health challenging environments [ 7, 8]. It is well known that the earliest attempts at this reorientation were initiated by global telecommunication providers and corporate philanthropic organizations. These sensed, early on, the potential of these m-Health markets, and the benefits to be gained from these opportunities [ 9]. These were followed by the profiteering IT and Internet giants, for the profit of healthcare providers, major healthcare insurers, and global pharmaceutical conglomerates. The business opportunities and the massive returns of investments (ROI) offered by the m-Health markets and services were tempting for these corporate organizations.

During the second decade of this evolution process, and as a result of this vast global corporate popularity and thrust, the support of the United Nations (U.N.) and its global institutions, such as the World Health Organization (WHO), International Telecommunications Union (ITU), as well as other global organizations sponsored by the telecom industries, such as (GSMA), followed suit and was eventually secured.

However, many of the earliest global mobile health initiatives and the mobile health strategies embraced by these established global institutions and organizations had limited impact, largely due to the dependency of these initiatives on potential market-driven models and opportunities, rather than real outcomes and tangible benefits.

These largely neglected the scientific aspects of the solutions used.

Furthermore, most of these remained largely localized, and within the pilot spheres, with no wider prospects to successfully scale up, especially in the poorer regions of the developing world.

Numerous studies highlighting these critical issues were published [ 6, 7, 8, 10]. This reorientation process led to the inevitable creation of the mobile health schism described earlier.

Most of these studies have repeatedly addressed the challenges associated with these initiatives, but without pinpointing to the original causes or proposing viable and practically applicable alternatives.

There are many other examples and critical aspects that can be highlighted on this matter; however, presenting the details of these is beyond the scope of this paper.

Most of the consumerization issues of mobile health, particularly in the areas of wellness, disease monitoring and management, and wearables developed, increased the market asymmetry of this schism at the expense of the science.

Whilst this market reorientation process continued unchallenged, many of the studies that seriously questioned these aspects, including larger clinical evidence, patient benefits, long term applicability, efficacy, cost effectiveness, behavioral change, privacy and security challenges, still remain debatable and uncertain [ 6, 7, 8].

Therefore, what has changed since then and why are we witnessing the recent shift from m-Health to digital health?

The answer to this question, which has remained undiscussed, is multifaceted and complex. Some of these issues are discussed next, whilst others are related to the original underpinnings of mobile health and the misguided interpretations of the concept that were described earlier.

These controversial ‘known unknowns’ were not discussed or disseminated in open literature prima facie until now, and are presented and discussed next.

For sections 3, 4 and 5

See the original publication

6. Discussion

The progress in mobile health (m-Health) over the last decade has been unprecedented.

This popularization was largely driven by the global markets of m-Health products, supported by the fast-evolving smart phone applications and the prevalence of their relevant digital technologies, but much less on the science and global evidence of mobile health.

This asymmetrical duality originated from the reorientation of the basic scientific and technological principles envisaged at its inception, towards the systematic and powerful subjugations of mobile health through the smart phone applications (Apps) prism.

The global pervasiveness and popularity of this version of m-heath and the dominating thought culture behind it, was aided by vast and dominating markets of the m-Heath applications popularized since the introduction of the first generation of the smart phones.

Nevertheless, this global and popular understanding of mobile health has been continuously scrutinized and questioned from clinical, scientific, societal, privacy, economic, among other areas.

Numerous clinical studies and pilots conducted within the last decade questioned these smart phone m-Health applications from different perspectives, such as clinical efficacy, cost effectiveness, patient acceptability and usage, larger evidence base, global healthcare benefits, and security and privacy among others.

This historic, yet powerful reorientation of mobile health transported the area to a continuous ‘flux mode’. It made this innovative area increasingly uncertain, scientifically and clinically limited on its impact, but vastly successful commercially. The origin of this conundrum was instigated by the powerful global health corporate conglomerates and their m-health ‘gate keepers’, who established and advocated this reorientation and sold effectively the global of m-Health business and not equally the science behind it. These were driven largely by market priorities and objectives, and less by healthcare benefits and evidence-based outcomes. Whether m-Health is one of the greatest technological breakthroughs of our time, or just another much-hyped healthcare technology bubble that could burst soon, is yet to be seen.

The fundamental causes and drivers for this m-Health schism are the ‘known unknowns’ or the ‘the obvious but sanctioned facts’ presented and discussed in this paper. The crux of these ‘known unknowns’ is the global reorientation of the m-Health landscape through the singular prism of smart phones and their ‘apps’ ecosystems. These have driven the powerful market economies of m-Health for nearly two decades. It is likely that these global trends will continue for the foreseeable future, supported by the continued growth of the global m-Health markets and their profiteering schemes, especially in the wake of the COVID-19 pandemic. These will be supported by the recent developments and the potential increase in the pervasiveness of the smart phones and its connected mobile devices, especially in the rapidly expanding markets of health monitoring and wellness applications.

Such modest revival remains ineffective in changing the overarching trends of mobile health, and of what is already a well-established and powerful global market. Furthermore, these research and scientific attempts were based on mostly invalid assumptions on the principles of mobile health.

These were studied from the same limited prism and narrow scientific pathways of smart phone centric approaches, and perhaps if not likely driven by specific views, research agendas and funding priorities.

However, some of the benefits of the ‘m-Health app’ centric applications have been reported from different applications and perspectives.

As an example for completeness, some of these from the patient and clinical perspective are presented [ 47]:

To support clinical diagnosis and/or decision making;
To improve clinical outcomes from established treatment pathways through behavior change and enhancement of patient adherence and compliance with treatment;
To act as standalone digital therapeutics;
To deliver primarily disease-related education.

Other benefits were also highlighted from the ‘digital intervention’ perspective and their strategies for different health and communications disciplines [ 28, 29].

However, in spite of these benefits, the global applicability and scaling of m-Health remains largely limited and debatable.

Most of the market-driven m-Health systems are confined to specific healthcare settings within the developed world, with the actual evidence provided so far supported mostly the use of these m-Health interventions in limited, but growing number of clinical scenarios [ 47].

The recent revamping of mobile health applications as ‘digital health’ will ultimately result in the same cycle of either ineffective or limited evidence-based outcomes.

This was widely seen during the COVID-19 pandemic, with the largely imperfect, limited usage and varying outcomes of these applications and tools, developed specifically in response to the pandemic.

These were largely based on smart phone application solutions, and mostly financed by private and public investments.

There is an urgent need to learn from these lessons and for radical revisions and an overhaul of the current thinking behind these strategies.

The need for new and preemptive m-Health systems that will have much more effective and tangible outcomes in response to this pandemic and other future global health threats and challenges is vital.

Many of the ‘known unknowns’ discussed in this paper that expose the totality and exceptionalism of this orientation of m-health are not widely studied or investigated.

These and other traits were not widely publicized or disseminated within the relevant m-health literature. Some of these are presented and discussed next for completeness.

6.1. The Age of m-Health Surveillance and Cybersecurity

The current m-Health systems are potentially establishing ‘global m-Health surveillance and cyber security age’.

The pervasiveness and global penetration of the m-Health apps, wearables, and other connected mobile devices are implicitly opening a Pandora’s box and leading to the creation of this worrying, if not dangerous, health surveillance age.

These devices and apps are rigorously marketed and sold in their billions by the giant IT, smart phone and other m-Health (digital health) conglomerates to support primarily their global business markets and landscape [ 39].

However, little is known on how the global usage of the acquired health and wellness data from these devices are facilitating a potential beach of privacy with surveillance and cyber security threats posed to the persons using these devices.

The unauthorized hacking, intelligent breaches and the monetization of the health data acquired from these devices is increasing globally. Some of the recent hacking occurrences and vast fines incurred on data privacy and security breaches are examples of such a worrying trend [ 48, 49].

These issues are just the tip of the iceberg and are growing concern. These critical issues from the m-Health or digital health perspective have not been widely discussed, with no large-scale research having been conducted on this topic from an m-Health perspective.

There are evident fears from the potential adverse outcomes of such research on the economies sustaining these systems, with possible user backlash and curtailing of the profits gained from these systems [ 39].

6.2. The Human and Behavioral Effects of the Long-Term Usage of Smart Phone Apps

This is another ‘known unknown’ of the current m-Health systems that has not been widely discussed before. Recent work has shown that the usage of smart phones has adverse, long-term behavioral and psychological effects, especially among younger populations [ 50].

For example, it is well known that the newer 5G smart phones and portable devices have higher harmful radiation effects and emissions levels, but the long-term exposure of these devices on human health has not been widely and rigorously studied yet [ 51].

The same can be said of the adverse effects of these devices used in digital health wellness and monitoring tools, and their potential adverse effects on long term basis.

The negative attributes of social networking, and the damaging psychological effects on younger children and adolescents, are being increasingly advocated with alarming levels worldwide [ 52, 53].

The funding for further clinical research on these and other harmful impacts and the long-term exposure and usage of smart phones and their tools is both timely and important.

The outcomes of these studies can lead to new findings that might advocate for healthier and less harmful alternatives to these popular systems.

6.3. Ethics of Mobile Health (Digital Health)

The ethics of mobile health (digital health) is another important area that has not been widely discussed and presented. This issues also relates closely to the privacy and security concerns as described above.

Some relevant ethical issues such as the minimization of the ethical m-Health risks of the expanding m-Health solutions, the increasing role of anatomy and virtual independency of these systems from standard medical evidence assessment, improved health literacy issues, the individualized empowerment from the participatory m-health solutions and others.

However, the strategic overhaul of these and other m-Health ethical aspects is likely to face surmounting challenges and diversified opinions from the policy, economic, governmental, patient, and healthcare provider perspectives.

6.4. The Rapid Developments of Science and Technology

These challenges are representative of the fast-moving developments in computing, sensing and communication technologies.

These represent the original pillars of mobile health [ 1, 2, 3, 4], representing the principal areas that have guided the development in this area over the last decade.

However, since these were largely encapsulated within smart phone technologies, they were never fully capitalized outside this technological landscape as discussed earlier.

However, in the wake of the COVID-19 pandemic, this reorientation illustrated more fragility than robustness in tackling the impact of this pandemic, and is likely to produce the same outcomes in response to future global healthcare challenges.

There is likelihood that, if the same process continues in the foreseeable future, especially in the age of rapid digital developments or the digital health era, it will most likely sustain the same cycle of globally unattainable, unaffordable and ineffective healthcare benefits, especially in the low-income and underserved healthcare settings.

Furthermore, these aspects contradict with the main goals set up by the WHO in their latest global digital health strategy and vision, which states that it aims to encourage digital health adoption worldwide with more inclusive and universal care for all, not only the few who can afford it [ 28].

6.5. Understanding the Science of Mobile Health

Understanding the science of mobile health is vital in this overhaul philosophy, and remains the major challenge in any radical change from the status quo.

For nearly two decades, mobile health has been debated as whether it represents an important area for the provision of improved and effective healthcare services via the combined science of the three fundamental pillar discussed earlier, or merely translated as medical and public health practice using mobile phones, patient monitoring devices, personal digital assistants (PDAs), and other wireless devices. [ 22].

Furthermore, this reoriented mobile health and interpretation is still being labeled as an emerging field without in depth understanding of the above important issues [ 5].

The proponents of these narrow and outdated interpretations of m-Health, representing one side of the schism discussed earlier, are either ignorant or unaware of the scientific principle of mobile health.

These important, yet rarely discussed topics need wider and more transparent debates from the scientific and clinical community interested in the future of this area.

These debates need also to establish an interdisciplinary framework of the scientific aspects of mobile health rather than the status quo.

There are also need for more in depth analysis on how best the science of mobile health can tackle the many global health challenges and future crises from the core scientific aspects and not these narrow understandings and limited scopes.

6.6. Curtailing the Effect of the Mobile Health Gate Keepers

It is likely that the next generation of ‘gate keepers’ will aim to sustain the modus operandi in the digital health era, for reasons that are evident, which mostly pertain personalized benefits and corporate sponsorships.

In particular, these strategies will focus on the continuation and enhancing the exclusivity of the recycled rhetoric of the smart phone apps ecosystems, supported with embedded intelligent/AI tools for enhanced efficiency and efficacy of these systems.

These will be widely marketed and advocated in next few years and used widely to redefine the new era of digital health.

The corporate mobile health gate keepers will reconfigure their earlier business and market strategies and remold these within new digital health sphere of services and products.

The radical overhaul and curtailing the impact of the gate keeper and their influence is vital for the future of m-Health and its true global impact and transformative benefits.

New policies and rethinking approaches are much needed to provide more inclusive and affordable mobile health or indeed new digital health solutions and systems that transcend the current modus operandi.

These can be thought of as more globally pervasive, clinically effective and widely applicable, and affordable with truly outreach capabilities.

These newly developed m-Health systems also need to be sustainable in the long term, with greater healthcare benefits, rapidly deployable, and particularly adaptable and preemptive to the future global health challenges and threats.

7. Conclusions

The paper presented some of the ‘known unknowns’ and undiscussable issues of mobile health (m-Health). These include presentations on the beginnings, original definition, and the fundamental pillars of mobile health.

The paper also presented the global reorientation of mobile health following the inception of the smart phone technologies.

This reorientation has led to the widely popular understanding of mobile health, viewed through the exclusive prism of the smart phone tools and applications or (m-Health Apps) singularity.

The evolution milestone by this powerful technological breakthrough represented a fundamental diversion in the evolution of this area, acting as a blessing and a curse.

The blessing was in the popularization of m-Health to unprecedented levels, with vast global markets that encapsulate the pervasiveness and applicability of the smart phones for numerous applications and clinical areas.

The curse was that it placed mobile health into a continuous flux of uncertainties, by creating the mobile health schism between its science from one end and markets from the other.

This divergence narrowed the outlook of this important area to global ‘m-Health Pilotitis’ landscapes, with lesser prospects of its much-hyped benefits, scaling up and impact on the global health scene.

This stealth reorientation has been continuous for more than a decade and will continue for the foreseeable future.

This version of mobile health will further inhibit its true healthcare benefits and global transformative aspects.

This trend can only be curtailed with the establishment of a more scientifically based m-Health-biased foresight and a new overhaul against this reorientation.

The re-introduction of digital health as a conjecture to mobile health is perhaps a reflection and outcome of this reorientation.

Many of the critical ‘known unknowns’ and undiscussed issues associated with this reorientation are also presented and discussed.

The basic philosophy presented in this paper is based on looking for the scientific alternatives outside the smart phone box, and beyond the m-Health Apps sphere, and more into the scientific aspects translated by the science behind the three pillars of the concept.

This new thought needs to be widely discussed and examined further by experts, clinicians and scientists and other ‘informants’ interested in this area.

This process must be reinvigorated by establishing a global alliance among scientists, research institutions, global experts and clinicians to re-establish the area on these scientific basis and understanding, and not to leave it exclusively to be driven by the global corporate influencers and mobile health (now digital health) gate keepers, who surreptitiously contributed to this schism and indoctrinated this reorientation into the global fabric of the area.

The ‘known unknowns’ presented in this paper exposed some of these undiscussable issues and translated these with some initial thoughts for further work and research in this area.

The new overhaul of mobile health and the scientific based outlook will be capable of balancing the fragile status of the increasing healthcare costs, quality, access and the increasing global health challenges facing humanity.

The lessons learned from the COVID-19 pandemic from a mobile health (or digital health) perspective and the modest or imperfect ‘global digital’ responses of the tools used during this pandemic need to be scientifically reviewed, studied and fundamentally revised in order for such an alternative vision of mobile health to be more effectively established and implemented.

However, this new science-based vision should not be a pretext for the recycling of the same reorientation approaches used over a decade, including a term change, but on novel scientific and technological frameworks that can provide a truly global mobile health access, affordable, and real quality care in the midst of increasing global healthcare challenges.