Medicine Unplugged

Just as the little mobile wireless devices radically transformed our day-to-day lives, so will such devices have a seismic impact on the future of health care. It’s already taking off at a pace that parallels the explosion of another unanticipated digital force — social networks.

Take your electrocardiogram on your smartphone and send it to your doctor. Or to pre-empt the need for a consult, opt for the computer-read version with a rapid text response. Having trouble with your vision? Get the $2 add-on to your smartphone and get your eyes refracted with a text to get your new eyeglasses or contact lenses made. Have a suspicious skin lesion that might be cancer? Just take a picture with your smartphone and you can get a quick text back in minutes with a determination of whether you need to get a biopsy or not. Does your child have an ear infection? Just get the scope attachment to your smartphone and get a 10x magnified high-resolution view of your child’s eardrums and send them for automatic detection of whether antibiotics will be needed. Worried about glaucoma? You can get the contact lens with an embedded chip that continuously measures eye pressure and transmits the data to your phone. These are just a few examples of the innovative smartphone software and hardware — apps and “adds” technology — that have been developed and will soon be available for broad use.

A recent mobile health report by Pricewaterhouse Coopers documented that consumers want these new apps and add-ons for their smartphones — but doctors are not enthusiastic. Why is that? From its inception, the medical profession has been characterized by information asymmetry. Doctors had control of all the data, information and knowledge. Not unlike the high priests before the printing press, the medical profession did all the essential reading. The great inflection of medicine is about to empower consumers to be able to read — not just a one-off measurement (like a blood pressure) but also data for all their relevant physiologic metrics, continuously, on the go. It will provide insights about each individual that we did not have before, such as how blood pressure fluctuates during a stressful event or during sleep. Such data will be graphed on one’s smartphone or tablet, and can be sent to a doctor, caregiver, or even a social network. And this is the precursor to having the key parts of your genome sequence — that which interacts with various prescription medications — maintained on your phone. Your phone, your DNA, your data.

But clearly the reach and impact extends far beyond accessing the individual’s metrics. Being able to diagnose a child’s ear infection remotely will pre-empt the need in many cases to see the pediatrician or go to an emergency room. Having one’s eyes refracted by a smartphone add-on leaves the need for an optometrist wanting. The benign skin lesions that so many people are living with but concerned about could get accurately diagnosed without a dermatologist. Phoning in the electrocardiogram data for someone with palpitations and lightheadedness obviates the need for a cardiology consultation or another emergency room visit. Capturing brain wave data along with oxygen level in the blood, heart and breathing rate with a home sensor would largely eradicate the need for expensive hospital-based sleep studies. If this doesn’t represent the beginnings of the greatest shakeup in medicine, then what does?

Physicians should not be fearful or threatened by the emerging smartphone-centric revolution of health care. The remarkable inefficiency of how medicine is currently practiced, along with its high costs, leaves enormous room for improvement. Rather than waiting an average of one hour for an office visit that lasts about seven minutes with the doctor, who typically spends the time looking at a keyboard rather than the patient, why aren’t we doing many office visits with secure video connects or even Skype and FaceTime? And having real face time. The relevant data on blood pressure, glucose, or whatever relates to the primary concern could be readily transmitted just before or during the visit. With the growing physician shortage that looms ahead, it’s all the more reason to embrace a new form of unplugged medicine. Note to my fellow physicians: It’s time to let go!

Eric Topol is chief academic officer at Scripps Health, a professor of genomics at The Scripps Research Institute and the author of The Creative Destruction of Medicine. This post first appeared at The Huffington Post.

15 replies »

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  3. @Eric – I hate the overused term, “a perfect storm,” but that’s what we have, creating the environment for the gee-whiz mobile health technologies described in your post. The pressures on office visits and home health visits is rising. Neither fee-for-service rates, which dominate in the former setting, nor case rates, which dominate in the latter, are equal to the task of creating sufficient face time for patients in need with health care providers — who are in shorter supply and higher demand — and office visits are not really needed for the sharing of information in the way you predict will happen in the near futue, and is happening already for some. So the tech has stepped in, and is accelerating the needed move to new blended approaches to payment and to managing health care and health care information.

    I am not so concerned about the overtreatment issue raised in connection with easy diagnoses of things like ear infections that often escape diagnosis and resolve on their own (interestingly, a similar issue was raised in one vignette in The Atlantic’s current issue’s article about Larry Smarr, whose extreme devotion to the quantified self approach let him predict the onset of his Crohn’s disease before he was at all symptomatic – and he was dismissed by his clinicians). This will moderate over time — and at least some of the early adopters (I would think most) should be more receptive to the notion that some things just don’t require treatment.

    @Joe – I like your Model T analogy, but I would caution that there were some other horses in the horseless buggy race, and just as we don’t see the progeny of the Stanley Steamer out and about on the road today, the health care tech roadside will be littered with failed startups founded on seemingly good ideas about how to marry tech to health care in a cost-effective manner.

    In order to bring new technologies to bear on health care, there are usually one or more regulatory hurdles to be dealt with, and the regulatory structures are already in place to slow down these innovations — maybe too much, maybe the right amount, maybe not enough — as they confirm that the whizbang devices are safe and effective, as well as cost-effective. We expect to hear from FDA this summer on the question of regulating certain mHealth apps as devices … and some of the hardware add-ons described in the post are already within the FDA’s ambit. The regulatory approval process adds years and dollars to the process of getting a product to market. Other agencies are interested in getting their fingers in the pie too, so even more cost and delay is possible.

    In the end, we are likley to see just a handful of successful apps and adds, despite that plethora of new ideas out there, because of the funding needed to stick out the review and marketing timelines, despite the growing eagerness of consumers (for now, just those on the quantified self bleeding edge, for the most part) and payors (and some providers) to adopt these new technologies. There is also the market issue, even in the absence of regulation. There are a zillion health apps avialable in the app store, but not many are downloaded in any significant volume, and those that are – are usually abandoned by users in short order becuase they don’t fit in with the flow of their lives. The dedicated quantified self crowd, engaged patients with chronic diseases, and a few others, are the ones carrying the torch here. In order to make a dent in cost, these things must go mainstream, and that has just not happened yet. Payors and providers may have to pay consumers to use them.

    @Michael – There are certainly roadblocks in addition to the FDA issues – local medical licensing laws and, of course, the question of liability when something goes wrong, to mention two you raised – but I’d agree with Joe that, in general, the rules will evolve, and the regulatory agencies — including both the turf-protecting state licensing boards, and the competing federal agencies — will develop more streamlined processes (they have to, since the FDA review cycle is longer than an app life cycle, and since mobility and technology are the tools we need to use to address the cost issues in providing health care services by health care professionals). The liability issue is nothing new, and will be dealt with as it has been to date, absent Federal tort reform (not holding my breath) or perhaps even a Federal decision to put a moratorium on it, like the sales tax moratorium used to jumpstart online commerce (just kidding).

    Interesting issues, and issues we will all be following closely for at least the next ten years, as the transformation of the American health care system continues.

  4. Some great comments here from Joe Flower, Michael Ricciardelli and very much appreciated. Regarding John irvine, if you read the PWC report the data support the assertion of marked consumer interest and lack of overall lack of support by physicians. For the cynics who have commented, I have no financial conflicts of interest with any of the technologies mentioned in this article. Cellscope makes the ear diagnostic add/app, Skin Scan and others make the dermatologic dx app, Alive-Cor makes the ECG add/app, EyeNETRA, an MIT spinoff, makes the eye refraction add/app, Sensicor makes the eye pressure contact lens monitoring device.

  5. These devices are one giant backwards leap for humanity, communication, and the soul.

  6. People say, “Patients are not ready. Doctors are not ready. The apps are not ready. The law is not ready.”

    Correct. Nobody is ready, nothing is perfect yet, there are problems to solve.

    It’s 1910. Ford Model T’s are pouring off the production line, and people are saying, “This’ll never work! Where do you get gas for these things? Who’ll fix them? It’s going to be a legal nightmare! The traffic laws are not up to this. The highways aren’t paved. This will put all the stables and stablemen in town out of work.”

    It’s 1910, and no one can envision the Interstate Highway System, drive-through Starbucks, and chains of gas stations.

    And not only the speed of consumer electronics and the Internet, but the speed of the growing demand for real solutions to healthcare access, mean that this revolution will be far faster than the time it took to get from the Model T to the Interstate. In 10 years, healthcare will look very little like it does today.

  7. A law degree is perhaps a blessing and a curse. Although I can see the benefits of portable consumer access eMedicine (for lack of a better term), the legal prospects seem dizzying–perhaps because the law is a slow moving creature and is grounded in such antiquated notions as geography. For example, what effect does skype consults have on state licensing provisions? Where exactly does the consult take place? I’m not being facetious–the law was particularly unprepared for the cybersphere– a quick look at the internet gambling quandry will show that in stark terms.
    I also, as another reader commented, find the prospect of machine/app failure and resultant misdiagnosis/malpractice to be difficult. The limitation of liability in this context is a major concern if one represents either the machine/app originator or the physician. You could envision protections similar to the limitations provided for 911 servers/software companies, but as the other commenter pointed out, this comes to money.

    Having said all that, I do think the comparison the author made to high priests is apt– the world changed with the invention of the printing press and the translation of the Bible into English. The accessibility literally stands at the heart of Reformation– but of course, the difference between a reformer and a heretic has a lot to do with where you’re coming from.

  8. @Fran Stevens, MD: Topol does serve as an adviser to a few of these companies. He’s usually good at disclosing which ones when he writes or speaks about them.

    If you’ve ever seen him talk about this in person or watched his TED talk (http://bit.ly/KD4N53) it’s easy to see that he is involved with this stuff because he genuinely believes in its potential. One of the most promising possible impacts, I think, Matthew highlighted in his review of Topol’s book http://bit.ly/y6GtgY

    Topol explains how digital medicine is going to transform the way we run clinical trials.

    But regarding this post, sometimes I think Topol gets a little overzealous about putting all of this data in patient hands. It is refreshing to hear a doctor advocate for less paternalism, but as Rob points out, not even doctors know what to do with all of this data.

    This movement shouldn’t swing too far in the direction of “the patient knows best.” Doctors get bullied by their patients. See James Salwtiz’s post on the pressure to order tests for patients because they ask: http://sunriserounds.com/?p=744

  9. I think Dr. Topol’s point about doing office visits with secure video connections is spot on. Who wouldn’t pay a few bucks to avoid getting into their car, driving across town, waiting for an hour surrounded by sick people when in many cases a video visit will do the trick. Worst case scenario is that you have to go see the doctor anyway.

  10. It sounds to me a lot like flying cars (which I am still disappointed about). I agree that this is an inflection point and that patient empowerment is much more likely to drive reform than legislation, but there are definitely some downsides to this. The ear infection detector, for example, will likely lead to a whole lot more diagnosis of ear infections that otherwise went away without treatment. There is lots of evidence that otitis gets better without treatment, even for febrile children. So telling people their kids have ear infections will more likely result in over-treatment than better care. We will be getting a whole lot more data that we have no idea what to do with, and information without a guide to tell us how to use it is a potentially dangerous (and expensive) thing.

    I agree, however, that improving access to care and decreasing the need for office visits will be essential to improving overall care. Obviously, payment reform to not require physical visits for payment will be needed to make this happen.

    I just worry that this is a case of “be careful what you ask for,” and not a “golden age of information.”

  11. All these apps can only help take care of the well-informed patient. Doctors fear the boat anchor legacy systems being vended under “meaningful use”. They suck!

    Patients should really have great fear. They will wait themselves to death.

  12. Such hyper enthusiasm for tech devices is indicative of financial conflict.

  13. If there is no one identifyable to sue, then the app or service or whatever will never gain traction because it will always be of suspect quality.

    If there is someone identifyable to sue, then they will want money for the use of the app or service or whatever. No normal person works for free.

  14. … “A recent mobile health report by Pricewaterhouse Coopers documented that consumers want these new apps and add-ons for their smartphones — but doctors are not enthusiastic. ”

    Not sure the evidence entirely supports this, Eric.

    I’m hearing that a lot of consumers don’t know quite what to do with this stuff.

    It’s a bit like talking about the China market – potentially huge and potentially game changing – but nobody seems to really get it.

    The tech savvy docs I talk to actually like this stuff more than consumers do.

    John Irvine