eHealth (Smart) Phone Home: What Can We Learn About eHealth From the Success of the Smart Phone?

We have been thinking about the effects that the smart phone has had on people and what this might teach us about what eHealth systems should be like.

The impacts of this smart phone technology have been life-changing, diffusing into society at an incredible rate and altering behaviors, communications, expectations and even relationships. It is not necessary to list all the smart phone’s influences here, because
we all can just reflect on our own experience and observe the smart phone’s (regrettably, both positive and negative) effects on those around us. Take a few minutes and observe your situation and surround. ‘Amazing’ is not too strong a word!

Later this Spring and in the Fall, NIHI is convening an online exploratory series of sessions (www. MenuItemID=537) to consider the effects of the smart phone and what we can possibly learn from it to improve the impacts of eHealth. Here we will share just a few reflections.

Why the Smart Phone has been so Successful – Thoughts
First of all, there may be an aspect of a technology’s success that has to do with the fact that a user can accomplish virtually everything in some domain of tasking without leaving the bounds of the software package. For example, Word has become ubiquitous because a writer can accomplish virtually anything desired, given the functionality of the product and its availability cross-platforms. He or she can compose or edit a brief email text, write an article, or produce a camera-ready book or virtually any other document. The fact is that Word is very complex and has a relatively long learning curve and word processors that had only limited capabilities (for example the writing of personal letters) have effectively disappeared. At the same time, Word has captured a humongous market. We can call this property “generality”. Generality means never having to leave the authoring (or other task) environment.

Realize that a smart phone also supports a very large set of kinds of uses. To name a few: verbal communications, text communications (both instantaneous and longer-term), scheduling and alarming, contact management, photography and photograph storage, maps and journey guidance, calendar, music, access to weather reports, games, access to electronic commerce, and on and on. In fact,
it is a set of functions only limited by imagination, form-factor and the apps one downloads. Today’s smart phones allow us to handle and finesse most of our daily tasks – you know the amazing array of functions they support. And they even allow us to use Word! We might call this the “Swiss Army Knife” capability.

Compare this to our eHealth applications. It is not uncommon that in eHealth systems users must move from application to application and sometimes even sign on to separate systems or separate workstations to carry out the panoply of functions for which they are responsible. This is true for both patient care and personal work, such as documentation, communications, and ones similar to those above.

Another reflection is that the Ubiquity of a technology is essential for its rapid diffusion to users. It has to be everywhere or go everywhere with us and everybody else must have it. Perhaps a good example of this is fax technology. Fax was used in a somewhat primitive form by the police (for sharing pictures of suspects or images of fingerprints, for example) decades before it became a business technology. The takeoff was slow, because in order for a fax machine to be of personal value, others with whom we wished to communicate had to also have the technology. However, there were other factors, including, perhaps most importantly, the development of standards for fax exchange. Different people could not have machines that communicated in fundamentally different ways or they would not have been interoperable.

So “Interoperability” (suddenly the ugly head of a devilish problem in eHealth pops up) is a primitive, must-have capability if we are to achieve rapid diffusion of a technology. So, some of the secrets of success seem to be: standards and interoperability as well as ubiquity and generality. To these must be added cost. Of course, the cost of the technology rapidly drops as demand for the technology increases. The reduction of cost often becomes exponential once a critical mass of users exists. But the cycle is vicious because cost depends on the number of consumers, and the number of consumers will only grow as the cost shrinks. Nothing is easy, is it!

Other important factors appear to be “Mobility” and “Always-Available Communication”. Mobility has been a crucial factor fundamental to the very nature of the smart phone. The smart phone is designed as a mobile device, initially around cellular communications capabilities, but its linkage to WiFi and its Bluetooth capability have been crucial enablers of rapid growth. It is interesting that early smart phones were quite small (especially compared to the Motorola “bricks” – or “shoes” if you prefer – we carried early on), with lighter devices with more usable screens following. These larger screens enhance the usability of applications like searching the Internet, visualizing images and entering data (because of larger virtual keyboards). Today’s smart phones are about as large as tolerable until unfoldable screens become available. Society has adapted to larger phones by providing a variety of holsters, now a standard part of dress (for those of the male persuasion, at least), that permit their carry and reduce the possibility of dropping and damaging them. Many have found out that sitting on one’s smart phone can be a crushing experience!

But that’s not all. It may be that another crucial enabler has been the “Simplicity of User Interface” and the practical disappearance of user manuals. Those of us longer in the tooth, may cry at the absence of user manuals. They were, at one time, a form of reading enjoyment useful for sleep induction. However, they were absolutely essential at one time and a crucial deliverable of applications producers. If you care (or dare) to look some up online, the user manuals for most smart phones are more than 100 pages long and are probably the least-read documents in the world.

The simplistic single button or tap smart phone screen interface has coerced all of us into a “youthful” approach to app use. This requires
(and tolerates – do older developers remember hoping users would not have “finger problems” and crash the app in days long gone?) “Experimentation” rather than following directive instructions. Users experimentally learn app functionality; they enter the app space and wander around trying things. The sheer complexity of user manuals was indicative of a technocratic approach to systems in the past. The simplistic no-manual approach perhaps taught us a more efficient way to learn functionality. Many who are of my advanced age can become apoplectic during this intra-application ambling. Of course, this is dependent on the ability of the systems to tolerate exploratory wandering without crashing – something that user manuals attempted to prevent through detailed instruction. This learning methodology perhaps more closely emulates the way we all learned as children to explore and discover the nature of the world.

There are other factors that have helped make the smart phone a game-changer. The “Robustness” of the technology is certainly a factor in its adoption and diffusion. In the past, just bumping a laptop or even a tablet could damage its disk or destroy it. Certainly getting it wet was a form of technological euthanasia. The fact that smart phones have become water resistant or waterproof and that dropping them from even a height of 3 feet won’t destroy them (especially if they have protective frames) is important. However, there are still issues in this regard. So both the vulnerability of software to finger-caused crashes and the potential for physical damage frustrated universal and rapid adoption of software and systems till the advent of the smart phone.

Sorry, Virginia, there is no Perfection
However, all is not wonderful with the smart phone and the new world it has created.

The existence of smart phone has helped some people to terminate their existence. Some try to text or to read messages while driving, causing so many accidents and killing so many people that there are now laws against this. This is the “Distraction Dysfunction” they engender. They also preoccupy people, sucking them out of the physical and social context and into the virtual vortex. Who needed to have something else to make our communication with our kids even harder?

For almost all users, the smart phone enhances social isolation – it is easier to interact with a distant person than the ones present.
Smart phones reduce or completely remove the normal boundaries between our work and our home and social environments. It becomes almost impossible to have a quiet personal or family evening or weekend. It’s the dream of labor slave drivers. Mr. Dithers virtually lives with Dagwood today. Now old Dag has a reason to sleep at the office. And Blondie is frustrated!

There are many other negatives, including how smart phones constantly attract and capture our attention, seemingly demanding repeated attention – we check them tens or even hundreds of times a day.

These devices create a bubble around us and it isn’t really escapable while they are around. The ultimate vacation might be where we take real people with us and leave the smart phone to entertain the cats.

We need to learn something from the insurgency of our phones. They have invaded our lives and transformed our work. They can serve as a model for what eHealth systems must become, but, like any great intervention they have side effects – and we must avoid those.

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