mHealth Developer Economics

Connectivity in Digital Health

The largest research program on mHealth

app publishing

November 2018
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Contents

1. Connectivity in mobile and digital health 3

Overview: How is digital health connected?

2. The connectivity landscape 6

Tool usage 6
Connecting to health data via APIs 7
Connecting to sensors and wearables 9
Connecting to API aggregators 10
Connecting to electronic health records 12
How will sensor connectivity change 13

3. About the mHealth Developer Economics program 15

What is it and how does it work?

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©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 3

1. Connectivity in digital & mobile health

This report is part of mHealth Economics – a research program about the publisher side of digital
healthcare. Since 2010 we have asked digital health experts about their opinion on the status and
future of digital healthcare. Since then we have collected 15,000
opinions from app publishers, programmers, physicians, project This report concentrates on
managers or product managers. The results of this report are
based on 2,400 answers.
connectivity in digital health
This report – the third of the mHealth Economics 2017/2018 series – focusses on to what degree
mHealth apps connect to wearables, medical devices, 3rd party health data, electronic health records
(EHR) and tools.

TODAY DIGITAL HEALTH CONSISTS OF A COMPLEX CONNECTIVITYECO-

SYSTEM WITH THE APP IN ITS CENTER

Ways to connect digital health data and their respective main use cases

Collect Display Recommend

Wearables & Tracking
sensors

-
Collect Display

Tools Medical Devices

Exchange

App

Collect Display
Aggregated health Electronic Health
data via API Records
Exchange

©Research2Guidance 2018

Today an app is much more than an app – in most businesses the mobile app is the focal point and
user interface within an eco-system of devices. In digital healthcare connectivity mostly consists of a
mobile app installed on a smart device. The app constitutes the center of the connectivity network
and can be connected to:
- Wearables & tracking sensors: Examples are fitness trackers, wristbands, smart watches, VR
headsets, UV sensors or thermometers.
- Medical devices: Exemplary devices are blood glucose monitors, stethoscopes, inhalers,
ECGs, smart beds or spirometers.
- Electronic health records: Personal health and fitness data in digital form. Data can be
exchanged between different parties: patient, physicians, labs, hospitals, health insurance
allowing all parties to have the same information.

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 4

- Health data aggregators: Access to structured health data managed by a health data
aggregator. Access is provided via an API. Data can be retrieved from and shared with the
data aggregator.
- Tools: e.g. testing, performance tracking, social networking, Digital health today
analytics, storing data or advertisement networks. consists of a plethora of
connectivity options
In this report we will show how connected the digital health world is
and we will give a brief outlook into the future.

Wishing you an enjoyable read,

Your Research2Guidance team

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

Learn more on www.chino.io
 7 REPORT TAKE-AWAYS

Today an app is more than an app

Apps are the center of a bigger ecosystem of connectivity options

81% of all mHealth app publishers are using tools

Tool users report 4 times more downloads compared to non-tool users

27% of mHealth publishers connect their apps via an API service

Sharing own data with others is becoming industry standard

42% of mobile health apps connect to sensors and wearables APIs

The decline of fitness trackers also effects apps connecting to external
sensors and wearables

50% of mHealth app publishers are using API aggregation services

Wearables APIs usage is declining due to increased usage of smart watches

49% of all mHealth app publishers are integrating EHRs & EHR
functionalities into their apps
Publishers from North America and APAC with highest EHR usage

Sensors built into devices will be most relevant category in 5 years’ time
Only 25% think that smart watches will be most relevant sensor category
2. The connectivity landscape
Tool usage
Using tools has become industry standard in mobile health app development. Four out of five (81%)
of all mHealth app publishers are integrating tools or SDKs1 in at least some of their portfolios.
Correspondingly, less than 20% are not using tools within any of their mHealth apps. Tool usage pays
off in number of downloads as tool users report four times more downloads.
According to our study results, healthcare tools and SDKs can be
classified into two groups: “must have” tools and “nice-to-have” tools. >80% of mHealth app
The “must have” tools are ‘testing and performance’, ‘social network’ publishers are integrating
and ‘analytics’. Those are used by a little less than half of all mHealth
developers. Tools belonging to the “nice-to-have” group are ‘storage’, tools into their apps
‘cross-platform development’ and ‘ad networks’. Those are used by
roughly a quarter of all mHealth developers.

81% OF ALL MHEALTH PUBLISHERS ARE USING TOOLS. INTEGRATION OF

TOOLS INTO HEALTHCARE APPS IS INCREASING OVER TIME

Which tools/SDKs do you use within your mHealth apps?

Change s ove r the l ast 2 ye ars

Testing & performance 47% +9%

Social network 47% +4%

19% 81% Analytics 45% -4%
Non-tool users +9% Tool users

(percentage points)
since last Storage 30% 0%
year
Cross platform tools 24% 0%

Ad networks 23% +5%

Other 9% 0%

Non-tool users Tool users

79k Downloads last year 362k
$162k External development budget $208k
12% Hospitals 3%

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

The integration of tools and SDKs into health apps has increased by appr. 10 percent points within
one year: it reached 81% (71% last study) – which indicates a mix of growing professionalism, better
technical eco-system and growing demand.
In a time-series comparison of a 2016-2017 period the functionality with the highest growth is
‘testing and performance’ (+9 percentage points). Also, ‘ad networks’ and ‘social networks’ have

1
SDK = Software Development Kit. SDKs are providing sets of tools (e.g. relevant documents, libraries, pieces of code or
guidelines) to develop software quicker and easier for a certain platform.
 7

gained popularity (+4 percentage points). On the contrary, ‘analytics tools’

Tools usage has have lost traction (-4 percentage points).

increased by appr. mHealth app publishers who are making extensive use of tools are more
successful: They are earning more money and they are able to generate four
10% YoY times more downloads and have a bigger budget for app development.
On the other hand, the group of mHealth app publishers that is not using tools, is characterized by
certain attributes: Above average non-tool users have not
implemented a monetization strategy. Non-tool users
often don’t aim for monetizing their apps at all. This is also
Tool user report 4 times more
a finding from a previous report, showing that a certain downloads over non-tool users
percentage of app publishers in healthcare have altruistic
motives. Hospitals are the most prominent subgroup of those non-tool users and non-monetizers.

Connecting to health data via APIs

Adding value to mHealth service offerings by incorporating third party health and fitness data points
has become a common practice in the digital health market. But
27% of mHealth how openly do they share their own data with others? They have
started. 27% of all mHealth app publishers are already offering an
publishers connect their API and 21% are planning to open their app for others enabling
apps via an API service access to their health data. Currently a little more than half (53%)
of all mHealth app publishers are not providing the possibility to
access their health data via API.

“OPENING UP” IS SLOWLY BECOMING THE NORM. 48% OF MHEALTH APP

PUBLISHERSARE OFFERING AN API OR ARE PLANNING TO DO SO.

Does your company offer an API that allows other mHealth apps to access your mHealth data?
Yes / PlannedNo

+4%

21%
Pl anne d 22%
No 56% 53%

Ye s 23% 27%

Own API offered No own API offered

$284k External development budget $145k
653k # of downloads (last year) 179k
26% Revenue millionaires (per year) 6%

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 8

Want to make use of our mHealth Economics program?

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©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 9

In a year-on-year comparison mHealth app publishers are becoming slightly more willing to provide
access to their data via API. The number has increased by 4
Sharing own data with percentage points over one year. Sharing data with others via API
might become the norm in healthcare soon – good news for
others is becoming more newer market players, who immediately get access to a wealth of
and more common valuable health data.
API and non-API publishers differ a lot. It looks like being open has
a positive impact on the company and the performance of their apps. Our research shows significant
differences between digital health companies offering their own API and those who don’t. The first
group has nearly two times the external development budget for app development. Those
companies also make significantly higher revenue than app publishers not offering an API. The group
offering an API has 4 times more “revenue millionaires” and the number of downloads is significantly
higher (around 3.5 times). As we know from our previous report (download here for free),
investment into mHealth app development pays off.

Connecting to sensors and wearables

The cooling down of the market for fitness trackers has also become
visible in the reduction of share of mHealth apps that connect to an 42% of mobile health
external sensor or wearable devices. Still in total 42% of mobile health
apps are connecting to sensors and wearables2. But, compared to last
apps connect to sensors
year the connection to sensor and wearables has declined by 16%. and wearables

42% OF APP PUBLISHERSCONNECT TO SENSORS.

Are you connecting to sensors/wearables?

58%
Don‘t use
sensors/
wear-ables
-16%
usage since
last year

42%
Use sensors/
wearbles

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

2
Wearables include all electronics that can be worn on the body including wristbands, watches, glasses, e-
textile, smart fabrics, bracelets, caps, and rings.

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 10

Overall, Fitbit is still the most connected-to sensor/wearable (52%), followed by iHealth and
Withings.
The wearables that have lost the most percentage point within the last year are Jawbone, Fitbit and
Mio (-5pp, -4pp and -3pp). Despite the average decline of connection to wearables, some companies
managed to achieved growth last year: Withings (+7pp), iHealth
and Garmin (both +5pp).
Fitbit is still the biggest
One explanation of this rather steep decline is that smart watches
are becoming more attractive for mHealth app publishers,
brand in healthcare
replacing other wearables. There were more than 50 Wear OS3 wearables.
watches available in Q2/2018 from a range of 3rd party
manufacturers like LG, Fossil, Ticwatch, Asus, or Huawei.

FITBIT API IS THE SENSOR/WEARABLE API WITH THE HIGHEST USAGE

AMONG MHEALTH APP PUBLISHERS.

Which of the following sensors/wearable APIs are you connecting to?

52%

Last year
This year
32% 31%
25%
23%
18%
15%
9% 8%
6%
5% 4%

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

Connecting to API aggregators

API aggregation services are bringing together APIs from different sources into one single “hub”,
pulling data from different sources, combining it and making it
available for third parties.
50% of mHealth app
API aggregation services have slowed down within the last year.
publishers are using API This year 50% of all mHealth app developers are using API
aggregation services aggregation services, which is 8% less than one year ago.

3
Wear OS is the new brand of Google’s former Android wear. Google re-branded the OS in March 2018 to
reflect the fact that one out of three Android watches were paired to iPhones.

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 11

50% OF MHEALTH APP PUBLISHERSARE USING API AGGREGATION

SERVICE. OVERALL API AGGREGATION SERVICE USAGE HAS DECLINED.

Are you using API aggregation services?

50%
use API
aggregations
services
-8% decline
of API users
since last year
50%
Don‘t use API
aggregations services

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

Apple Healthkit is by far the most popular service with two thirds (63%) of API users opting for Apple.
Number two is Google Fit (45%). All other API service providers are
used by 20% or less: Open mHealth, Samsung Health, Human API, Apple HealthKit and
Validic and Qualcomm Life. Google Fit are the most
used API aggregation
services

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

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APPLE HEALTHKIT IS THE MOST POPULAR API AGGREGATION SERVICE USED

BY 63% OF MHEALTH APP PUBLISHERS

Which API aggregation services do you use?

1 APPLE HEALTHKIT
63% -4% 5 HUMAN API 10% -2%

2 GOOGLE FIT 45% +1% 6 VALIDIC 9% -5%

3 OPEN MHEALTH +5% -3%

20% 7 7%

4 SAMSUNG HEALTH 15% -3% 8 ORANGE HEALTHKIT 3% -1%

Changes since
last year

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

Although there is only little fluctuation in mHealth app publishers’ preferences between the API
aggregator services year on year, smaller API aggregators will have to add additional service layers to
their offerings to not end up as a too small niche player.

Connecting to electronic health records

Electronic health records (EHRs) are digitizing the medical and beyond-medical (e.g. fitness) data of a
patient or user. Data points from different sources are unified and stored centrally facilitating the
data flow for all parties involved: physicians, hospitals,
laboratories, insurers and patients. 49% of all mHealth app
By now, 49% of all mHealth app publishers are integrating EHRs publishers are integrating
into their mobile apps – including functionalities of their apps
that serve EHR purposes. EHRs & EHR functionalities
The share of developers integrating EHRs in 2017/2018 is virtually into their apps
identical to last year.
There are big regional differences in to usage and integration of EHRs and EHR functionalities in
mobile apps:
- mHealth app developers from the APAC region have the highest percentage of EHR integration
(69%).
- North American mHealth app publishers show the second highest EHR integration (58%).
- Developers from Europe have the highest share of health apps without EHRs (38%).

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

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49% OF ALL MHEALTH APP PUBLISHERSCONNECT THEIR APPS TO EHRS OR

TO EHR FUNCTIONALITIES

Does your app/do your apps integrate with Electronic Health Records?

This year 49% 51%

Last year 48% 52%

YES NO

YES (This year) NO (This year)

49% Average 51%

58% North America 42%
40% Latin America 60%
38% Europe 62%
69% APAC 31%

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

What do the current developments in EHRs mean for mHealth app publishers? Integrating electronic
health records into apps is a major cost and time factor. When developing a healthcare app that
includes EHRs approximately two thirds of the costs can be allocated to include EHRs. In the future
more and more tools and services will arise, which will help developers leapfrog the strenuous task
of EHR integration.
In the future EHRs might be much more than a mere storage of health data. A patient’s EHR could be
accompanied by AI, which would be able to provide the
healthcare professional with recommendations – and additionally The integration of EHRs into
transfer relevant data to public health officials. As of now, EHRs
are more a data input burden for healthcare practitioners instead
mobile apps accounts for
of intelligent assistants in the patient journey. the majority of
development costs
How will sensor connectivity change
Connectivity to sensors will allow mHealth apps publishers to incorporate user / patient data
automatically measured into their apps.
mHealth app publishers have been asked, which sensor categories they see most relevant in the next
five years. The results are clear. The most relevant sensor category in the future will be sensors built
into devices. 65% digital health experts qualify built-in sensors as most relevant.
Wearables like wristbands will stay relevant according to 52% of mHealth app publishers.

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

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IN THE NEXT FIVE YEARS SENSORS DIRECTLY BUILT IN DEVICES WILL

DOMINATE OTHER DIGITAL HEALTH SENSORS

Which sensor categories will be most relevant for mHealth app solutions in the next five years?

e.g. accelerometer, heart rate

Built-in to smartphone / tablet 65% measured with phone's camera

Wearables 52% e.g. bracelets, helmets

e.g. blood glucose meters,

Plugged-in or wirelessly connected 45% thermometer, blood pressure meter

e.g. glucose detection for control of

Implantable sensors (in-body) 36% diabetes

Intimate contact 29% e.g. stick-on tattoo sensors

Watches 25%

Ingestible sensors 13% e.g. camera pills

Other 1%

©Research2Guidance 2018
Source: Research2Guidance - mHealth App Developer Economics study 2017/2018 - n = 2,400

45% of app publishers think that plugged-in resp. wirelessly

connected devices will be most relevant in five years’ time. Only 25% believe that in 5 years’
Implantable sensors take a mid-range place in relevance
(36%).
time watches will be the most
Only 29% think that intimate contact devices will be the
relevant sensor category
most relevant sensors for mobile health apps – and 25%
believe in watches as most relevant sensors in 5 years’ time. Ingestible sensors (e.g. camera pills)
have the least amount of relevance with only 13%.
Time will tell.

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 15

3. About the mHealth Developer Economics program

The mHealth Developer Economics is a global research program analyzing the digital health and
mobile health market. For eight years, we have been monitoring the market for digital health, its
current status and future trends. In total, we have analyzed more than 15,000 digital healthcare
businesses and decision makers over the course of 8 years. The mHealth Developer Economics
program is the world's largest digital health research program.
The research program explores the economics behind the development of
7 million data digital health solutions, including the size of the digital healthcare market
points and 15,000 and its segments, the performance of available solutions (downloads,
MAUs, revenue), the business models used, the preferred marketing
answers from channels to promote mobile health apps, segments of app publishers,
mHealth experts platform preference and API usage, indications covered, the role of key
stakeholders including payers,
since 2010 pharmaceuticals or accelerators, and future mHealth Developer
developments in digital health.
Economics: The largest
In the last mHealth Developer Economics survey cycle, conducted
between March and August 2017, more than 2,400 decision makers and program about digital
mobile and digital health professionals contributed their opinion. health globally
Answers have been collected globally, with most answers coming from
Europe (47%) and from North America (36%). The rest of the participants is from Asia-Pacific (11%),
South America (4%) and Africa (2%).
The majority of stakholders in mobile health is from the health industry itself (60%): Medical device
manufacturers, Pharma companies, health insurers, hospitals. The remaining 40% are non-healthcare
players (IT / tech companies, consulting companies, app developers) and insitutions like universities,
NGOs and “others”.
The digital health market is characterized by a relatively low level
3% of the global mHealth of experience: 28% of its market players have only recently
industry participated in entered the market in the last two years. 67% have less than 5
years of market experience. This fact should be kept in mind
last year’s survey when reading this report.
The report at hand analyzes the technical aspect of developing mobile health apps, especially the
tools and SDKs used in mobile health app development and the role of EHRs (electronic health
records). It answers questions like: What are the most common use cases integrating third-party
tools? Are mHealth app publishers offering an API for others to access their mHealth data? How else
are APIs used in digital health? Are mHealth apps integrating EHRs?
To find out more about the status and trends in a year-on-year comparison, please have a look at the
‘mHealth Economics 2017 – Current Status and Future Trends in Mobile Health’ report, (published in
November 2017). For an overview of how to monetize mobile health apps, download our according
report for free.
We would like to thank all survey participants and partners for their contributions. We hope this
work provides you with valuable market insights.

Sincerely,
Your Research2Guidance team

©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com

 16

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©Research2Guidance 2018 – mHealth Developer Economics – www.research2guidance.com