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The hackathon model to spur innovation aroundglobal mHealth

Pantelis Angelidis, Leslie Berman, Maria de la Luz Casas-Perez, Leo AnthonyCeli, George E. Dafoulas, Alon Dagan, Braiam Escobar, Diego M. Lopez,Julieta Noguez, Juan Sebastian Osorio-Valencia, Charles Otine, Kenneth Paik,Luis Rojas-Potosi, Andreas L. Symeonidis & Eric Winkler

To cite this article: Pantelis Angelidis, Leslie Berman, Maria de la Luz Casas-Perez, LeoAnthony Celi, George E. Dafoulas, Alon Dagan, Braiam Escobar, Diego M. Lopez, Julieta Noguez,Juan Sebastian Osorio-Valencia, Charles Otine, Kenneth Paik, Luis Rojas-Potosi, Andreas L.Symeonidis & Eric Winkler (2016): The hackathon model to spur innovation around globalmHealth, Journal of Medical Engineering & Technology

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INNOVATION

The hackathon model to spur innovation around global mHealth

Pantelis Angelidisa*, Leslie Bermanb, Maria de la Luz Casas-Perezc, Leo Anthony Celid, George E. Dafoulase,Alon Dagand,f, Braiam Escobarg, Diego M. Lopezh, Julieta Noguezc, Juan Sebastian Osorio-Valenciag,Charles Otineb, Kenneth Paikd, Luis Rojas-Potosii, Andreas L. Symeonidisj and Eric Winklerd

aUniversity of Western Macedonia, Kozani, Greece; bUnited Nations Population Fund, New York, NY, USA; cInstituto Tecnologico y deEstudios Superiores de Monterrey, Monterrey, Mexico; dMassachusetts Institute of Technology, Cambridge, MA, USA; eAthensUniversity School of Medicine, Trikala, Greece; fDepartment of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston,MA, USA; gEscuela de Ingenieria de Antioquia, Envigado, Colombia; hUniversity of Regensburg Medical Center, Regensberg, Germany;iUniversidad del Cauca, Popayan, Colombia; jAristotle University of Thessaloniki, Thessaloniki, Greece

ABSTRACTThe challenge of providing quality healthcare to underserved populations in low- and middle-income countries (LMICs) has attracted increasing attention from information and communica-tion technology (ICT) professionals interested in providing societal impact through their work.Sana is an organisation hosted at the Institute for Medical Engineering and Science at theMassachusetts Institute of Technology that was established out of this interest. Over the pastseveral years, Sana has developed a model of organising mobile health bootcamp and hacka-thon events in LMICs with the goal of encouraging increased collaboration between ICT andmedical professionals and leveraging the growing prevalence of cellphones to provide healthsolutions in resource limited settings. Most recently, these events have been based in Colombia,Uganda, Greece and Mexico. The lessons learned from these events can provide a framework forothers working to create sustainable health solutions in the developing world.

ARTICLE HISTORYReceived 24 February 2016Revised 21 May 2016Accepted 23 May 2016Published online 9 August2016

KEYWORDSmHealth; hackathon; Sana;global health; healthinformatics

1. Introduction

Engineers have become increasingly drawn to prob-lems in healthcare.[1] The challenge of providing qual-ity care to underserved populations in remote ruralsettings has, in particular, attracted a lot of interestamong engineers seeking to provide societal impactthrough their work. Sana is an organisation hosted atthe Institute for Medical Engineering and Science atthe Massachusetts Institute of Technology (MIT) thatwas established out of this interest. The group con-sisted initially of engineers, doctors, entrepreneurs andpublic health practitioners from Harvard and MITbrought together by a passion to improve health out-comes using technology, but rapidly expanded as itattracted colleagues especially from low- and middle-income countries (LMICs).

Information and communication technology (ICT)has generated considerable enthusiasm with its poten-tial to expand the reach of a limited supply of special-ist expertise. Mobile health, or mHealth, exploded ascellphones became not only ubiquitous but also more

powerful. An estimated USD 4.3B was invested indigital health technologies in 2015 alone, supportingthe creation of >160,000 iOS and Android health-related apps.[2]

The hope that problems in global health with socialcosts will be solved by technology alone is unrealistic,however, so much so that failures and disappoint-ments in the promise of technology are inevitable.High-tech innovations addressing low-hanging fruitsabound but very few attempt to tackle systems-levelfactors contributing to poor health. Clinical aspects ofthe disease may be addressed but not its social deter-minants. To date, no mHealth app has been adoptedacross populations and led to sustained improvementin health outcomes.[3] An mHealth app, or any innov-ation for that matter, is fated to fail unless it is incor-porated into a comprehensive, systemic solution thatattempts to address the multitude of issues at handwith respect to a particular disease.

This paper describes Sana’s ideas incubator initiativethrough hackathon events around mobile health, or

CONTACT Alon Dagan adagan@bidmc.harvard.edu Department of Emergency Medicine, Beth Israel Deaconess Medical Center, 330 BrooklineAvenue, Boston, MA 02215, USA*All authors contributed equally to this manuscript and are listed alphabetically. MIT Sana Global Team, 77 Massachusetts Avenue, E25-505, Cambridge,MA 02142, USA� 2016 Informa UK Limited, trading as Taylor & Francis Group

JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY, 2016http://dx.doi.org/10.1080/03091902.2016.1213903

mHealth, in resource-constrained settings. AlthoughSana is not alone in its use of hackathons to spurinnovation around mHealth,[4–6] the group and itsglobal partners believe there is value in sharing theirexperiences and lessons learned through this report.

A hackathon brings people from various back-grounds together for problem-solving. They are typic-ally organised as intense, short-duration competitionswhere teams generate innovative solutions. The hacka-thon model integrates collaboration, idea generationand group learning by bringing together differentstakeholders in a mutually supportive setting. In 2015,Sana organised mHealth engineering bootcamps andhackathons across the globe with a diverse mix ofpartners. The Sana mHealth engineering bootcamp isan intensive 2- to 4-day programme to accelerate pro-ficiency in global health informatics, to leverage inter-national engineering resources and build mHealthcapacity. The programme is designed to introducecomputer science, informatics and engineeringstudents to mobile health, providing them with thetechnical concepts as well as the clinical perspectivesto effectively design and implement mobile health sol-utions. Immediately following the intensive bootcamp,the students are teamed up with local clinicians orother experts in the field to share ideas and innovatein an organised hackathon, bringing theory intopractice. The 2- to 3-day event allows the participantsto immediately apply the concepts and lessons onactual projects, working in multidisciplinary teams todevelop rapid prototypes and solve real problems.These projects may then be continued as research orstart-up ventures, while other students can benefit bycontinuing with more extensive health informaticstraining. We write this report with our colleagues fromColombia, Uganda, Greece and Mexico and sharelessons learned from the mHealth events.

2. Hackathons

2.1. Colombia hackathon

Popay�an, Department of Cauca, Colombia was the siteof mHealthColombia,[7] a week long mHealth boot-camp and hackathon in June 2015, led by Sana, localacademia, and the ICT industry, with the objective ofdeveloping mobile solutions to healthcare problemsspecific to the Colombian ecosystem. The event wasmotivated by interest from the Colombian governmentin innovating processes in healthcare and ICT.

The lack of digital records in the Colombian health-care system was identified as a significant challengeduring preparations for the mHealthColombia eventand therefore chosen as one of the primary areas offocus. Existing mobile applications and frameworkssuch as Sana Mobile were proposed as tools thatcould be incorporated into solutions. Presentations byinternational experts and descriptions of existing toolswere provided during the 3-day bootcamp, held priorto the hackathon, to help improve the understandingof issues relevant to mHealth, as well as the technicalskills of the hackathon attendees. Four primary healthtopics were addressed during the workshops as sug-gested by local stakeholders: telemedicine, caregiversupport, standards and interoperability and quantifiedself. In order to generate a creative atmosphere toidentify relevant health problems, the event took placeinside a complex of medical clinics. Participants inter-acted with patients and ICT professionals to spawnideas and iterate their prototypes with help from endusers.

More than 70 participants were grouped into 18interdisciplinary teams who received advice from men-tors from MIT, Massachusetts General Hospital –Harvard Medical School, Universidad del Cauca,Universidad EIA, Universidad CES, Tecnologico de

Colombia hackathon

2 P. ANGELIDIS ET AL.

Monterrey (Mexico), Microsoft Colombia, FraunhoferInstitute Germany, Pan American Health Organizationand Cluster CreaTIC. Mentors assisted the participantswith product development, market analysis, pro-gramme monitoring and evaluation based on theirexpertise in mHealth in different countries and con-texts. Projects revolved around wearable technologiesand personal health records as well as improving com-munication between patients and their caregivers.

The majority of the participants were students withsignificant software development skills resulting in pro-totypes having a reasonably advanced level of develop-ment. Limited participation of healthcare providers,however, presented a considerable shortcoming. Whilea significant number of clinicians were invited to par-ticipate, very few showed up for the event. It is notclear if this were due to lack of interest, insufficienthealth ICT training in medical school, or limited avail-ability. Most likely, there was little incentive for health-care providers to attend. Those who work in publichospitals or clinics have to find coverage for their clin-ical responsibilities while those who work in the privatesector lose potential income to attend a 2-day event.Finding ways to address these conflicting needs and toinclude more physicians in the unavoidable digitalisa-tion of healthcare represents an ongoing challenge tothe country.

Overall, mHealthColombia was still hugely successfulbecause it created new opportunities for collaboration,as well as entrepreneurship provided by the start-up

accelerator CreaTIC. The event assembled a communityof developers, and fostered networking with localindustry and international partners.[8]

2.2. Uganda hackathon

The United Nations Population Fund (UNFPA), in part-nership with Sana, organised a global “Hack ForYouth” in Kampala, Uganda in July 2015. The hacka-thon challenged 80 participants from 17 countries todesign and develop creative technology solutions toadolescent sexual and reproductive health (ASRH)issues. UNFPA convened a diverse group of partici-pants, including young people and youth developers,as well as stakeholders from academia, UN agencies,and public and private sector that were experiencedor operational in ASRH initiatives. Drawing on UNFPA’score focus and experience supporting programmingfor young people, active youth participation through-out the hackathon helped to bring the user perspec-tive to the forefront, guiding the design of theplatforms conceptualised during the hackathon.

The hackathon’s specific thematic focus in address-ing ASRH challenges guided the structure of the event.Globally adolescents and youth face significant health-care concerns, including risk of adolescent pregnancy,child marriage, HIV and AIDS, intimate partner violenceand limited access to contraception.[9] This is evidentin Uganda where teenage pregnancy rates are 24%,[10]over 140,000 unsafe abortions occur annually among

Uganda hackathon

JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY 3

young women aged 15–24 years,[11] and young peopleaccount for a significant percentage of new HIV infec-tions.[12] In this context, we believed that a hackathoncould provide an opportunity to find innovative newmeans to address specific challenges that young peopleexperience in safeguarding their sexual and reproduct-ive health, such as barriers to receiving health informa-tion or accessing youth-friendly services.

Given the diverse set of stakeholders participating inthe hackathon, including programmatic and technicalexperts, as well as young people, UNFPA was inten-tional in developing a toolkit (or “Playbook”) to guideparticipants throughout the event. Rather than theusual primarily self-directed hackathon programme, thePlaybook provided a step-by-step programme throughthe Sana innovation design process. The toolkit fos-tered radical collaboration and human-centered designprinciples to encourage liberal brainstorming andunconventional, innovative solutions. This was imple-mented because most of the participants were inexperi-enced with hackathon events and many came fromrigidly structured operational environments, where thedesign process was unfamiliar. The Playbook can easilybe adapted to other hackathon contexts, and draws ondesign thinking principles. The hackathon teams werepreassigned to ensure a diverse multidisciplinary com-position, taking into account the geographical prioritiesand contexts that would guide each team’s solutions,as well as language requirements. In advance of thehackathon, an online survey was developed to drawinput from youth globally, to identify the ASRH prob-lems they encounter, ensuring a greater number ofyouth voices were part of the hackathon.

From the start of the hackathon, the participantswere encouraged to identify the key ASRH challengesthey wished to address, without focussing on specifictechnology solutions to encourage divergent creativeideas. Over the next 2 days, guided by the Playbookand supplemented by topical workshops on operatingASRH programmes and mobile health design theory,the teams iterated their designs and built mobile appprototypes. Each of the teams received guidance andfeedback from Sana and UNFPA, providing mentorshipin mobile health and ASRH. The hackathon concludedwith a public pitch session where an expert panel ofjudges and the public voted to select the winningprototypes.

The success of the UN in convening such a diversegroup of stakeholders involved significant challenges.It proved difficult to find the right balance betweenorienting the technical participants to the specificASRH content, while also ensuring participants wereaware of the potential technologies that they could

utilise in their solutions. This also impacted the overalltiming of the event, including balancing the necessaryorientation, design and development periods, along-side demos of mHealth platforms created by youthdevelopers in Uganda, press conferences, and team-building activities. Furthermore, the global nature ofthe hackathon meant that after the hackathon, follow-up efforts would be more challenging.

Recognizing these challenges, we determined thatan active follow-up plan would be necessary to ensurethe greatest impact from the hackathon. In the follow-up to the hackathon, three of the winning teams aredeveloping their detailed proof of concept and imple-mentation plans for platforms related to sexual harass-ment reporting, gamification of ASRH information, andsupport to community health workers to reach youngmothers, with support from UNFPA and mentors fromSana.

2.3. Greece hackathon

The Aristotle University of Thessaloniki, in collabor-ation with the Department of Informatics andTelecommunications of the University of WesternMacedonia, organised a Sana mHealth BootcampWorkshop and an mHealth Hackathon in October 2015in Thessaloniki, Greece.[13] Health scientists, innovatorsand engineers guided students in the identification ofsignificant local healthcare problems and developmentof solutions based on open source mHealth technol-ogy. Participation by students in the event presentedan important opportunity given the current low rankGreece has in mHealth market readiness among theEuropean Union countries based in part on developercompetences.[14]

Following the Sana approach promoting multidis-ciplinary participation, the event included graduateand undergraduate students from engineering, healthinformatics and medicine as well as healthcare experts,developers, innovators and entrepreneurs active in theGreek mHealth business sector. In particular, healthprofessionals working in the national health system aswell as in research participated thanks to the endorse-ment of the event from the 4th Regional HealthAuthority of Central Macedonia and the Faculty ofMedicine of the Universities of Thessaloniki andThessaly. Attendance consisted of 110 students (out of180 that applied) for the mHealth bootcamp with 45participating in the hackathon.

The objectives and agenda of the bootcamp discus-sions were around global health challenges relevant toGreece and the application of mHealth technology toaddress these challenges. Participants attended talks

4 P. ANGELIDIS ET AL.

from local experts to increase their understanding ofthe complexity of healthcare issues, including obstaclesto providing high quality care. Lectures and hands-onexercises provided participants with an introduction tomHealth software development tools, platforms, andthe utilisation of existing open source software. Topicsincluded design thinking, clinical decision-making,Android programming, medical data standards andontologies, clinical data analytics, Electronic HealthRecords (EHRs), medical devices and sensors and regu-latory issues. Case studies of Greek mHealth applica-tions through real-life demonstrations and interactivepanel discussions were presented.

The hackathon provided an opportunity for clini-cians, entrepreneurs, scientists and engineers to worktogether as they identified local health needs anddeveloped open source mHealth solutions. The hacka-thon started with participants pitching problems, fol-lowed by the formulation of multidisciplinary teams.The bulk of the hackathon was spent on prototypedevelopment using the material and tools presentedduring the bootcamp. Ten teams developed AndroidmHealth applications from smoking cessation to

communication aids for the deaf and mute. Smokingrepresents a significant health problem in Greece withsome of the highest rates in the world.[15] The hacka-thon concluded with project presentations and anawarding ceremony.

2.4. Mexico hackathon

In early January 2016, Sana and the Tecnol�ogico deMonterrey in Mexico City hosted a similar bootcampand hackathon event focused on the needs of thegrowing geriatric population.[16] This event was devel-oped with the support of MIT International Scienceand Technology Initiatives (MISTI), Graduate School ofEducation, Humanities and Social Sciences ofTecnologico de Monterrey, the Medix Laboratories Co.,CinepolisKlic Co. and Microsoft Research Azure Co. Thelocal community of physicians and researchers choseto focus the efforts of this hackathon on the geriatricpopulation given the significant challenges facingelder care over the next years. In Mexico, the fastestgrowing segment of the population is those over 65,with a predicted census of 15.3 million by the year

Greece hackathon

JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY 5

2030.[17] Compounding this challenge of a growingelderly population is the number of geriatricians avail-able. To date, Mexico has approximately 500 formallytrained geriatricians. The event therefore focussed onmobile health solutions to address the growing needsof the elderly population.

Attendance reached 75 participants broken into 11multidisciplinary teams composed of telecommunica-tion and computing engineers, biotechnologists, highschool students, social workers and geriatricians. Theweek began with 2 days of presentations coveringboth the clinical needs of the geriatric population aswell as technical tutorial in and design strategies formHealth software development. The bootcamp set thestage for a 3-day hackathon where 11 groups devel-oped novel and diverse mobile health solutions, fromassisting patients with urinary incontinence exercise toconnecting caretakers and patients through a socialnetwork app.

This hackathon was successful primarily because ofthe attendance of geriatricians during the weeklongevent thanks to the commitment of the director of alocal geriatrics programme. Clinical input from idea

generation throughout the design process was crucialin identification of relevant problem areas and devel-opment of solutions that address not just the clinicalcondition but the social determinants as well.

This hackathon was unique with the inclusion ofhigh school students. Despite their relative lack ofexperience, the students were extremely enthusiasticand were able to make significant contributions totheir teams. Those without technical experienceassisted with presentations and marketing plans. Initialconcerns that the high school students might feelintimidated working with graduate and undergraduatestudents were dispelled. By the end of the event, thehigh school students were pleased with their contribu-tions, and expressed strong interest to participate insimilar events in the future.

3. Lessons learned

One of the most fundamental challenges faced by thehackathon community is how to define and measuresuccess. Is success measured by the number ofmHealth app prototypes at the end of the event? Is it

Mexico hackathon

6 P. ANGELIDIS ET AL.

the number of start-up companies that are spawned?Or the participants’ experience and learning from theevent?

The success of an event must include an assess-ment of the event as experienced by the participants.Since the events typically occur over the course of sev-eral days, assessment of the participant experienceshould occur throughout the event as well as in theform of a thorough review once the event has con-cluded. The most critical source of that informationcomes from the direct feedback provided by the par-ticipants themselves. The primary approach employedfor obtaining this feedback has been to engage partic-ipants in informal discussions either individually or inlarger groups. In that context, a number of themesemerged that reflect the hackathon experience. Someare more easily measured such as whether the envir-onment provided a network with adequate connectiv-ity, a sufficient number of power outlets were present,seating was available for all the participants, anadequate number of restrooms were available, toname a few. Additional subjective measures includethe general level of noise or other distractions, level oflighting, room temperature and availability of refresh-ments. In general, a successful event should provideparticipants with an environment that is comfortableand conducive for creativity.

Product commercialisation has not been the focusof the Sana hackathons for several reasons. A recentstudy from Harvard Business School found that 95% ofstart-ups between 2000 and 2010 failed to see theprojected return on investment. Start-ups in thehealthcare arena tend to address low-hanging fruits;any potential benefit is trumped by muchbigger issues in the rest of the healthcare value chain.Better clinical outcomes, the objective of everyhealthcare start-up if it were to succeed, almost alwaysrequires a multi-pronged, inter-disciplinary, collabora-tive approach, which often runs counter to the entre-preneurial spirit. Hackers need to understand betterthe systems-level issues in healthcare delivery if theyare to create sustainable and scalable solutions. Theyalso need to know what have been tried, what havefailed and why they failed so as not to “reinvent theflat tire”. More important than mobile health applica-tions, what is needed in systems-level innovations.While incredible advances have been made to health”gadgets“ like low-cost point-of-care diagnostics, orwireless monitors, what remains to be developed areinnovations that will integrate these components intohealth systems in a manner that can be brought toscale. The global health community need innovationsin the delivery infrastructure that is supported by an

information system that distributes and integrates caredelivery most efficiently. This is the key message thatSana tries to impart to the hackathon participantsthrough presentations from local healthcare expertsand interactions with local mentors.

Beyond the impact hackathons have through thesolutions they generate, they provide authenticlearning experiences that promote content mastery,development of technical and thinking skills, andcreation of supportive professional and social net-works. They have been championed as a powerfulnew pedagogy, able to provide students opportuni-ties to learn and solve problems in authentic con-texts, using twenty-first century skills andtechnologies, and to break down walls betweenclassrooms, peers, role models and mentors.However, little formal research has been done onthe types and mechanisms of learning during hacka-thons, or how these are impacted by the designand execution of these events. To that end, Sana isorganising a summer 2016 workshop called “HackingHackathons” that will bring together Sana hackathonalumni from around the globe to share their experi-ences and lessons learned, and work with educationexperts to maximise the learning from these events.The goal of “Hacking Hackathons” is to partner witheducation organisations such as the MIT TeachingSystems Lab that have experience in evaluating edu-cation programmes for quality improvement in orderto define and refine our approach to capacitybuilding.

At the end of the day, the Sana mHealth boot-camps and hackathons are not about the apps built,but more about the relationship fostered between theengineers, the healthcare providers and other partici-pants. It is about the software developers acquiringthe deeper level of understanding required to solvecomplex, systemic health problems. It is about thehealthcare providers becoming empowered toimprove the way they deliver care and appreciatingopportunities to contribute to innovation. Achievingthese goals is challenging to measure, and for thatreason, improving these bootcamps and hackathons isdifficult.

4. Final remarks

Technology alone will not improve health outcomes.This is a crucial message that we emphasise in everyhackathon. ICT, as in every technological innovation inhealthcare, has a number of prerequisites for success.The main objective of the hackathons is therefore tobring together engineers with their technical skillset,

JOURNAL OF MEDICAL ENGINEERING & TECHNOLOGY 7

clinicians who are most knowledgeable about theproblems in healthcare and other experts includingpatients and end-users. We believe that understandingall the layers of complexity is the crucial first step toleverage advances in ICT in order to improve health-care delivery, and that this is only possible through amultidisciplinary approach.

Disclosure statement

The authors report no conflicts of interest. The authors aloneare responsible for the content and writing of this article.

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8 P. ANGELIDIS ET AL.

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