Why Mobile Apps Have Not Been Widely Adopted by Physicians
Everything You Need To Know About Mobile (Written For Investors & CxO’s)
By | Sherri Douville & Dean Shold
Just as in all things digital and this 4th industrial revolution, understanding mobile experience and performance is all about following the data. You should care about this because a leading cause of preventable death is still a delay in information.
The purpose of this post is to explain unreliable app behavior for example, when you can have bad app and Internet performance despite showing full bars on your cell phone. You can be standing next to a repeater showing full bars on your phone and have a strong wireless signal without the ability to open mainstream mobile apps. [1] Speed of data to and from your phone determines if apps crash, open, and when there is latency or delay in transmitting data. There is also the problem that data speeds are not as advertised as explained here on why promised speeds frequently don't deliver.
The uncoordinated reality of multiple industries (Mobile network, smartphone, chip, wireless) contributes to the disaster of unreliable apps in healthcare. This means that bad internet performance on mobile in health must be mitigated by the app maker. This should be done from a software perspective.
As a consumer, phone makers tout “better” coverage than older phone models when selling new phones. This comes with huge caveats. Everything boils down to understanding how data gets transmitted and downloaded. Doctors frequently face the worst combination of factors contributing to bad connectivity, slow data, and bad app performance. This is in part, why so few mobile apps have been truly adopted by physicians in healthcare. While physicians outside the hospital will be impacted by the mobile network, in the hospital they are on Wi-Fi for security reasons. We define important terms for both mobile network and WiFi in this post.
Many people ask us why mobile is so different from traditional enterprise applications and those historically used by consumers. It all boils down to speed of smartphone data downloads. Speed of data is determined by a combination of:
- Modem is part of the SoC/chips used in the mobile devices (pictured below) which underpins slower computing and has to be responsible for more functions with less space than a computer CPU chip does impacting connections with Wi-Fi. Different modems deliver vastly different real-world 3G and 4G performance for smartphones. For example, almost 500,000 user tests on T-Mobile and 570,000 user tests on AT&T showed average download speed differences of 53–68% with worst-case download speeds varying 97–192% for two dominant modem brands.[2]
- Software that tunes the phone’s hardware/SoC. Mobile phone computing is intentionally designed to be slower for smartphones in order to control for managing heat that can damage your phone. Slower computing = flaky connections which has to be addressed.
- Distance from cell towers & access points (Wi-Fi)
- Network congestion
- Amount of radio frequency interference in hospitals
- Building materials like lead walls and even most glass
- Carrier performance: For example, Verizon is best with iphone.
The reliability & performance of a mobile app depends on its design for the factors above. We’ll review next the big things that make mobile so different in hospitals. The big picture is that there is no correlation between how apps work outside a hospital and if they’ll work inside its walls. First we’ll review topic 1 from above about mobile hardware. Below that, we’ll address points 3,4,5, & 6 as they relate to signal interference for mobile in hospitals.
- Here’s what’s inside a mobile phone “chip”called a System on a Chip. All these items pictured below are packed together in one small unit in a smartphone. In contrast, all of these components are separate hardware items on a desktop computer. Smartphone (SoC) and desktop CPUs have different expectations and different goals.
2) The problem in hospitals is that the biggest barrier to connection is interference between the phone’s radio and Wi-Fi signals.
You can think of Wi-Fi as simply two radios communicating back and forth over a short distance. These two radios have historically allowed for web users to download data from the Internet as well as upload information using Internet Protocol to communicate.
When your data is flying through the air in radio waves, it can be stopped and greatly slowed by interference. It can be blocked by a myriad of things including other Wi-Fi signals, radio waves emitted by microwave ovens, cement walls, cancer equipment, and even most glass. This is when the legacy apps crash or don’t open.
Why the Consumer Solution Doesn’t Work for Doctors
Carriers have tried fixing this for consumers by providing faster speeds for 3G and then 4G. The problem is that Physics dictates that the LOWER the frequency, the farther a transmission can go. Conversely the faster 4G and 5G, higher frequencies are successively shorter electrical sine waves; these are proportionately impacted by interference and obstruction. (resulting in signal blocking, the opposite of what they intended). With Wi-Fi, 2.4 gigahertz is the older and lower frequency which can reach computers located farther away than a recent 4G of 5 gigahertz band can. This shortening of distance with newer 4G and 5G bands, combined with interference, is why hospital connectivity for mobile devices is getting worse, not better.
Both well meaning and shrewd vendors will recommend you use extenders or repeaters as a solution to this problem. If you deploy repeaters on a weak signal that is coming from one unit to another unit, you’re only repeating that weak signal. Therefore, if your wireless Internet is only transmitting at half the speed it should, the repeater will repeat that signal by pushing out an even weaker signal to the end user’s smartphone.
Slower processing on mobile phones contributes to unreliable app behavior due to unreliable connections that have to be designed for. Medigram is designed to solve this by coming up and opening; though messages won’t flow until that connection is resumed. Crucially, we did pick our technology for its ability to resume connections and maintain them at lower bandwidth than traditional and consumer apps are designed for. Bandwidth as defined precisely in computing terms (as opposed to signal processing or spectral terms). Bandwidth in computing refers to the rate of data transfer, bit rate or throughput, measured in bits per second (bit/s). RE: https://en.wikipedia.org/wiki/Bandwidth_(computing)
One reason why Whatsapp (who also uses Erlang for architecture, not just messaging) delighted users is because it was able to perform for the EDGE network (which is amongst the slowest wireless technologies as defined in Kbps vs Mbps below). Most of the best hospital network architects will admit that through no fault of their own, and because of the physics of the environment, that hospital Wi-Fi networks behave more like EDGE or 2G to a physician on a mobile phone. For those of you interested, we’ve included brief definitions and a backgrounder on wireless technologies below.
Backgrounder on Wireless in order of history
1G, 2G, 3G, 4G, 5G etc refers to the different generations of wireless communication technology characterized by having a defined range of speed.
The four BIG networks in the U.S. belong to Verizon, AT&T, Sprint and T-Mobile. In the table below, you can see which 3G and 4G LTE bands and frequencies these carriers put out. Figuring out which and how many of these signals your device works on will determine whether physicians will have a good experience on that network outside the hospital.
GPRS (General Packet Radio Service)
GPRS is a packet-based wireless communication service. It is a 2G technology network that support a download speed of up to 114Kbps.
EDGE (Enhanced Data GSM Evolution)
GPRS and EDGE are both 2G technology but EDGE is significantly faster with a download speed of up to 384Kbps.
3G
Introduction of 3G network made video calling and streaming of video possible, with download speed of up to 3.1Mbps.
HSDPA (High-Speed Down-link Packet Access)
It is based on the 3G network and an enhancement to 3G. Brings faster speed, download speed can be up to 14Mbps.
HSPA+(High-Speed Packet Access) is an evolution HSPA ( HSDPA & HSUPA). This is a 4G technology that allows download at a rate of up to 168Mbps.
4G LTE (Long Term Evolution)
LTE is a 4G communication standard that supports HD video streaming, download speed as high as 299.6Mbps.
5G (ONLY a Marketing term) At this point, 5G waves would be too short to support physicians on mobile phones in a high interference environment such as a hospital.[3]
Takeaway: In a hospital on mobile, distance and interference matter for signals to reach the smartphone determining if the app can open and work.
Can Signals Go The Distance?: 5G is shorter than < 4G/LTE which is shorter than < HSPA+ which is shorter than < HSDPA which is shorter than < 3G which is shorter than < EGDE (longest reaching but slowest connection)
In summary, there are a lot of factors impacting the physician’s experience with any mobile app. It will take at least a decade or more to normalize all the technology sectors involved in healthcare mobile to support legacy, mainstream enterprise and consumer app approaches. Choose a vendor who has built a system with all of this in mind to support your doctors so they can focus on saving lives.
By: Sherri Douville, CEO & Dean Shold, CTO at Alameda Health System
Sherri Douville is CEO and board member for Medigram, the Mobile Medicine company. Recognized in 8 categories of top CEOs by Board Room Media (Across SMS, mHealth, iOS, IT, Database, Big Data, Android, Healthcare). Top ranked medical market executive worldwide. Best selling editor/author, Mobile Medicine: Overcoming People, Culture, and Governance & Advanced Health Technology: Managing Risk While Tackling Barriers to Rapid Acceleration, Taylor & Francis; Series Editor for Trustworthy Technology & Innovation + Trustworthy Technology & Innovation in Healthcare. (contracted to advise top academic and professional education publisher Routledge, Taylor & Francis).
Sherri is the co-chair of the IEEE/UL JV for the technical trust standard SG project for Clinical IoT in medicine, P2933. She is passionate about redefining technology, software and data for medicine and advanced health technologies in a way that’s worth the trust of clinicians, our family, and friends. Ms. Douville leverages her books to inform her work on the CHIME CDH security specialization certification board. She also teaches, advises, and co-founded the Cybersecurity (+AI) curriculum for the Black Corporate Board Readiness and Women’s Corporate Board Readiness programs at Santa Clara University.
Dean Shold is the CTO for Alameda Health System. Before his current role, Dean was the VP of Technology For Medigram and before that served as VP of Infrastructure and Chief Technology Officer for Stanford Health Care, and was previously the VP of Global Data Operations for Zephyr Health. With a degree in computing science and a passion for social good, real time data analysis and mobile computing, he brings a unique background and perspective to the healthcare industry. At Medigram, Dean drives enterprise customer complete solution development, implementation, support, and customer success. At Stanford Health Care, he led a global team of 180+ personnel at 24x7 support to 50+ locations including multiple hospitals. He managed the technology and support budgets and built and reorganized teams to drive performance and reliability. He built a command center based on FEMA’s (Federal Emergency Management Agency Guidelines) and oversaw data center performance and builds.
Dean also has deep passion for practically addressing the opioid crisis. His interests are in the scientific and the social sides of the opioid crisis bridging the people who use drugs and are opioid dependent with the researcher and the lawmaker. He is fascinated by how the worlds of legal and illegal opioids intertwine and how our societal biases impact treatment and recovery. In his work, he brings a vision of how Health IT can be leveraged to better understand and address the crisis. This includes examining the following key dimensions in addition to Health IT such as fentanyl, naloxone, harm reduction, detox, treatment and recovery.
Outside of the office, Dean also co-founded a non-profit organization to create novel ways to donate to charities. Dean is an instrument rated pilot and avid music lover. He and his wife, Pauline recharge by exploring harm-reduction organizations, the arts, craft beer and music scenes.
[1] JOHN PATRICK PULLEN TIME Magazine April 24, 2015 “Here’s How Wi-Fi Actually Works”
[2] Forbes “New iPhone Leak Confirms Apple’s Serious Problem” July 26, 2018 by Gordon Kelly
[2] Elizabeth Woyke March 10, 2017 MIT Technology Review
Worthwhile read for understanding why the smartphone is slower than your P.C. RE: https://www.makeuseof.com/tag/smartphone-desktop-processor-differences/
Note: The difference in data transmission on EDGE/2G in KB vs. 3G & 4G in MB. Mobile apps have to adapt!
Math refresher:
