Terry H. • From the perspective of a seed investor, the trial reported in this article (and published study) and the NEJM published study mentioned in this article, appear to produce fairly weak outcomes. They are unlikely to justify the considerable investment and implementation risks associated with the need to change re-imbursement systems for clinicians and obtain patient compliance.

The problem appears to revolve around the assumption that improved information, even where a clinician will act up on it, will change the course of events at the patient level.

However, as with other wireless based monitoring systems, the issue may be a lack of understanding of the patient personal and social context. Understanding this context may instead lead to the development of systems that use factors such as peer pressure and personal motivation to lead to changed patient behavior, without the intervention of clinicians.

It is probably no accident that a number of the wireless health companies that started out as wireless widget developers, whose widgets centrally reported data, are morphing into on-line community/social network managers.

Dr Nayana S. • @Terry - as an investor, which types of mobile apps do you see potential in ?

Terry H. • Dr Somaratna, FWIIW, the group in which I am a small participant, confines it's activities to apps. that do not depend upon mass adoption by clinicians, mobilize incremental household expenditure on health care amongst the middle classes in any country, are a "must have" for patients and their families and are peer group driven (based upon behavioral economics insights), do not use expensive "first world labor" in delivery and have low regulatory barriers. Unfortunately, this means we have only invested in a couple of deals over the last two years. These criteria are not all that different from what I see many others applying. The jury is still out as to whether we are correct. Hope this is helpful.

Dr Nayana S. • Thanks Terry ! Just for perspective - I am a mobile apps entrepreneur myself (with an audience of 300,000 healthcare personnel).

If you don't mind my asking one more question : what is your opinion on paid vs. free apps?

Tim I. • Terry - what dies the acronym FWIIW stand for?

Tim I. • Hi Terry - your perspective seem to be less focused at the hospital readmission problem for CHF and more in line with less intensive social behavioral applications for "general" and "overall" health or wellness. If I have mistaken your application will you clarify?

When you are concerned with CHF symptomology that will lead readmission you need to monitor clinical parameters are actionable by the patient and the healthcare support network - up to and including the physician. I will agree that the UCLA project using weight, BP and activity level are relatively non-specific...but it is a start.

Parameters that emphasize peer pressure or personal motivation that lead to a change in patient behavior may help that extremely small percentage of the CHF cohort interested in making a change in their overall personal health outcome but for the most part - morbidity in CHF population is primarily due to a severe lack or absence in motivation to change behavior. The emphasis in not of "general" health it is keeping these patients out of the ED and back in the hospital.

The UCLA Wanda project attempts to make it simple and easy for patients to report their progress, or lack thereof, toward decompensation and point out indicators requiring lifestyle changes. There are other peer reviewed clinical parameters being studied that fit the wireless health management model (simple home monitoring device/patch) that give specific indications of worsening hemodynamic conditions and a prospective flag for potential 30-60 day readmission.

Terry H. • Dr Somaratna, I do not have any particular views or expertise as to pricing of apps. I note the obvious that amongst the 7K or so on the iOS platform, many appear to ignore the well trodden fundamentals of user perceived value pricing.

To give an example with which I am very familiar. The app "Neuro Toolkit" is an outstanding collection of tools, which is very useful to the quite small market of neurological and interventional radiology teams. These teams can typically insert a US$10K stent into a brain and use angiography and other scanning technologies that cost US$Ms. In one hospital system I know, every member of the interventional radiography/neurology team privately purchased an iPhone to get access to this app, which itself retails for the princely sum of US$4. My guess is that the developer could have charged a little more!

Terry H. • Tim, Thanks for your well reasoned comment. I wish you well with your CHF monitoring widget.

My original comment was, as stated up front, from a venture seed investor's perspective. That is, I could not see that many of the wireless widgets could be effective without a surrounding service infrastructure and by extension, therefore, I doubted that the returns would accrue to the widget vendors. My guess was that the returns would mainly accrue, in the first instance, to the service vendors. This was just standard Porter/Christiansen/Moore type analysis.

In addition, in order for the service vendors to be viable, they had to be able to work in an environment that rewarded better patient outcomes and reduced costs. This may be true say within the USA VA or Kaiser style insurer/payer/provider systems, but it is not true in systems such as those in Australia, Japan, or China, which still reward entitlement based fee for service, or in some cases, fee per drug prescribed.

I also was and am still skeptical as to the scalability and sustainability of service vendors that use high cost (professional) labor. Most of the trials of home HCF and other systems use such high cost labor, even if they try to utilize it more efficiently via the net. The problem, in my view is that most such systems are not "high touch", as they simply cannot afford to use much such labor. Whilst software can be used to some extent to "embody in capital" and replace labor, at the front end of most systems (e.g initial diagnosis algorithms), in the end, most value is derived from human interactions. My guess is that the systems that mobilize low cost but highly professional labor to serve middle class patients, will triumph. This will work in most countries.

Such "low cost" labor includes:

1. Peer to peer household (often mainly female) labor - there are numerous examples of peer and membership based a-spatial online health care communities, where the members look after each other and produce superior outcomes - I have direct experience of HF and end of life communities where P2P networks add enormous value.

2. Servicing affluent middle class persons, with "high touch" professional services, from low cost locations.

My guess is that people who solve these types of issues will add a huge amount of value for patients and make some money.

Interestingly, this pathway is similar to that being followed by players in the international higher education industry.

Hope this is useful.

Dr Nayana S. • Hello Terry,

Thank you very much for your perspectives on mobile apps ! I certainly have a lot to think about now.

Christian R. F. • Hi Terry, yeah I agree with you. Can you name any mobile health initiative/program which incorporates a (social) health community (by social I mean Facebook) where people watch over each other?

Terry H. • Christian, There may be some apps out there that use Facebook platform for mobile messaging and data feeds, but I know of none. I am peripherally involved in porting a couple of chronic care communities from more traditional messaging systems and manual entry data acquisition, to Facebook groups for release later this year. Sorry cannot assist.

Christian R. F. • Terry, no problem. Keep me updated on your work. I would like to see the Facebook group once you are finished. I would like to get a feeling for health communities...how people participate and how it actually helps in terms of compliance and effective treatments.