The Smartphone Physical

What if the next time you step into your doctor’s office for an examination, she reaches into her white coat pocket and pulls out an iPhone instead of a stethoscope? That’s the idea behind The Smartphone Physical, a re-imagination of the physical exam using only smartphones and a few devices that connect to them. These include a weight scale, blood pressure cuff, pulse oximeter, ophthalmoscope, otoscope, spirometer, ECG, stethoscope, and ultrasound. Want to know more? I’ve answered some questions here for THCB. And have a few myself.

What are the pros and cons of using smartphones for clinical data collection?

Smartphone penetration in virtually every market has exceeded expectations, and healthcare is no exception. More than 80% of physicians in the US have smartphones, and of those three-quarters use them at work. Much of this is currently personal communication, but increasingly physicians are using smartphones as reference tools; between 30-40% report using their smartphones for clinical decision support. It seems like a logical next step to go beyond reference apps and to start using peripheral devices, such as cases that convert the smartphone into an ECG or otoscope as well as peripherals such as pulse oximeters and ultrasound probes, for easy and reliable data collection.

At TEDMED we found that using our smartphones and the clinical devices actually improved our ability to engage with the “patient,” because we were able to share and explain the physical exam findings directly at the point of care. We could take a quick snapshot of the carotid arteries and tympanic membrane and, for the first time ever, show the patient what theirs looked like and field any questions they may have. Ideally in the near future we’d be able to go one step further and upload this data to the patient record. That is one of the most powerful aspects of the Smartphone Physical because we will be able to establish baselines for individuals. For example, instead of the current model of a primary care ophthalmologic exam, where a physician will write “W.N.L” or “unremarkable” for a patient without a concerning optic disc finding, we will be able to take and store an actual image of what the patient’s optic disc looked like at an earlier time-point. This may be particularly useful for patients who present years later with concerning visual changes.

Furthermore, smartphone-based collection of clinically-relevant data will help patients become their own data collectors. This may abstract away the mundane and standardize the unreliable aspects of the physical exam, and allow for trending data that needs to be taken in context and not just at once-yearly visits (e.g. blood pressure, temperature, etc).

Those are a few examples of the benefits that may be achieved through the integration of smartphones into the clinic. There are, of course, potential drawbacks. One of the most obvious concerns affecting the whole BYOD (Bring Your Own Device) movement is that of patient safety. Most physicians use their personal smartphones and would thus be collecting and storing potentially sensitive data on their phones. There would certainly be issues were these to be compromised. This is an issue facing other industries as well and some smartphone-makers, such as Blackberry, have responded by separating the hard drives- one for personal use and the other for business use, which is encrypted and can be scrubbed on a daily basis. Another workaround is to have a devoted smartphone or tablet for the clinic to collect data. A second potential negative of the integration of smartphones into the clinic is that it may distract from the patient-clinician relationship, especially if the clinician is not used to such devices. This is common to almost every form of technology and may be overcome with appropriate training and practice.

How can the Smartphone Physical be applied in medical education?

I think medical education may be the first to benefit from the devices we included in The Smartphone Physical. This applies not only to how we educate our future clinicians, but also to how we educate and engage our patients. If a patient can easily correlate their blood pressure, for example, to their salt intake they may be more likely to change their diets – especially if the smartphone has an alert system if one’s blood pressure has been trending upwards.

Back to medical school, when students first learn the clinical exam there’s a lot of “see one, do one, teach one” going on. The issue with some of the physical exam maneuvers, particularly those that involve seeing or listening asynchronously with the instructor, is that the student may not fully comprehend how to perform the exam. A fourth year medical student told me that he had never actually gotten a good visualization of an optic disc until he used the smartphone ophthalmoscope, and that’s a common theme. At Hopkins I brought the device to clinic and had a very productive training session with an ophthalmologist who was able to get a good image and teach both me and the patient about the fundus. I’m looking forward to seeing more of these devices integrated into schools.

I’m personally very interested in devices that can be carried around by clinicians. Most of the devices we included in The Smartphone Physical are small enough, and in particular there are a few that serve dual functions as clinical data collectors and protective cases for the phone. For example, the smartphone ECG and the smartphone otoscope are both in the form factor of an iPhone case. This allows clinicians to always be ready if the need arises, e.g. in the case of the ECG if someone complains of chest pain or faints at a public event (if only we also had a smartphone defibrillator, which I’m positive someone somewhere is working on). I’m also excited about devices that will empower and engage patients so they can connect with and understand their own bodies. One caveat is that this may lead to a small minority of patients to go overboard, e.g. I’m concerned in particular if the smartphone ultrasound ever becomes available to the broad public that some helicopter-parents-to-be will purchase or lease a unit and expose their babies to repeated sonograms. Proper education and device regulation should help circumvent this.

What’s next for the Smartphone Physical?

I will continue curating additional devices that may be added to the Smartphone Physical. These can be found on our website, Smartphone Physical, and already may include a smartphone-based glucometer, breathalyzer, thermometer, and even a thermocycler/PCR! My team is working with device manufacturers to make these more available for medical education and global health purposes as well. In terms of studies of these devices, there are many pilots going on that are being run by independent parties as well as the device manufacturers and we will be paying close attention to these results to see if outcomes are improved and/or costs are reduced. As with any technology, the cost-benefit analysis needs to be done to make sure we are making progress and not simply falling into a tech trap. In terms of patient training, to my knowledge there have not been formal programs set up, but there will certainly be a need for this that will likely be filled by the device manufacturers who want to get their tools into the hands of patients. We’ll be sure to update you if any major announcements come up.

The Smartphone Physical and You (Feel free to add responses in the comments thread.)

1-Are you currently using any smartphone-based clinical devices, or are you planning to incorporate them into your practice/home?

2-Do you have suggestions for other devices that should be included?

Shiv Gaglani is a 3rd-year medical student at Johns Hopkins University, an editor at Medgadget, and curated the Smartphone Physical at TEDMED 2013.

26 replies »

  1. Technology grows every day and smartphone come with many Apps. Then it can do many things to make more convenience for our lifestyle. Thanks for great articles.

  2. Hi Jon, would love to learn more about Zipnosis. Very interested in telemedicine and how elements of the Smartphone Physical may be leveraged to get more clinical data to improve physicians’ ability to make tele-diagnoses. Please e-mail me at shiv.gaglani@medgadget.com if you are interested.

  3. Hi Peter, I wholeheartedly agree that the ideal situation would be for our heatlhcare system to combine “high touch” with high-tech, where cost-effective, and to become more preventive as opposed to reactive. This will take a cultural shift, perhaps beginning with improved education and access to healthcare. Ideas are welcome!

  4. Thank you, Mike!

    You’re right on that currently there are devices that are more appropriate for patients to use and those that are more appropriate for clinicians to use. There are primarily two major dimensions that determine whether a device should fall into the former or latter category: accuracy and ease of data collection. Theoretically there may reach a point where simple, portable devices can be used by laymen to collect virtually any clinically relevant piece of information. That’s the goal with the tricorder. However until devices such as the ultrasound and ophthalmoscope become intuitive enough to use, accurately, we’ll still need clinicians or at least trained workers (e.g. in low resource settings, global health corp workers) to administer these tests. Some data is inherently best collected in the ambulatory setting over long periods of time, to track trends. This includes anything with variable baselines, such as blood pressure, heart rate, and temperature. For some discussion about this, check out the interview with RTTV: http://bit.ly/ZYBHP6.

    Some of the devices are almost as powerful as, or in some cases more powerful than, their clinical counterparts. For example, the EyeNetra is starting out with a global health application but believes it can disrupt the optometry market even in developed nations. I think other device manufacturers believe their smartphone-enabled devices can accomplish similar goals, especially through added value such as the ability to record and store images of optic discs and ear drums.

    Happy to discuss further, feel free to message me at shiv.gaglani@medgadget.com.


  5. Thanks Karan!

    Your comment about sleep studies is one reason I was sad to see the Zeo go out of business. Their CEO had an insightful post last week on MobiHealthNews about the limitations of consumer-based health devices (http://mobihealthnews.com/22410/can-personal-health-data-motivate-behavioral-change-it-depends/).

    A checklist or criterion list is a good idea. There are groups that are curating medical apps, e.g. Happtique, but being able to compare traditional versus smartphone-based devices is something I’m personally interested in. Message me at shiv.gaglani@medgadget.com if you want to continue discussing.

  6. Hi Kenny, thanks for your response. Can you share the link to the audiometry device that is smartphone-based? We may add it to The Smartphone Physical! Agreed with you on the second point that more data is not necessarily better. We learned that lesson from genomics, that data does not mean insight and insight does not translate necessarily into actionable steps. In terms of changing behavior, some patients may be swayed by pictures but you’re right in that we need better ways to motivate patients to change their lifestyle behaviors.

  7. Hi Shirie, thanks for your message. I haven’t seen anything like what you’ve mentioned – most of the workflow apps I’ve seen are for outpatient practices and not check-ins for operations. The security concerns are definitely real, especially because the smartphones and tablets being used in the workplace are often also used for personal purposes. I’ll return to this should I learn of anything like what you’re mentioning.

  8. This may sound ironic but it isn’t: how about an iPhone/computer charger that runs off a bicycle or a treadmill and you have to go for an hour to charge it fully?

  9. @Whatsen,
    If smartphones are too small and provide insufficient data, what about the value to the patient in partnering with the provider to direct efforts at something that might be wrong? This would be beneficial to those patients who are attuned to their bodies who could then have confirmation of conditions or redirection for different conditions. This then puts the provider in the role of expert consultant and uses that specialized knowledge in a more efficient way.

  10. Engaging post – thank you. It’s wonderful to hear a physician’s perspective on how to use the smartphone for clinical care. For all the talk of the technology, there is a critical and delicate transition that must occur between the patient and physician as each brings their own device(s) to bear on the diagnosing process. As a patient, if I use my own otoscope at home I want to know that my physician will trust and use that in their diagnosis. Conversely as a physician, I want to know that the quality of the information I’m using is the best I can get. That’s at the foundation of Zipnosis’ business – building a trusted, but digital, connection between patients and providers for diagnosis and treatment. It’s simple medical care today, but it grows as we leverage objective data via the phone – either from the pt or the provider. So keep pushing the boundaries on the devices/tech necessary. Some are technology, some are legal and some are frustratingly human.


  11. From NCBI:

    “In Cuba, health care is considered a human right for all citizens; health care is therefore a national priority. Cuba’s health policy emphasizes prevention, primary care, services in the community, and the active participation of citizens. These emphases have produced an impressively high ranking on major health indicators, despite economic handicaps. The Cuban experience demonstrates the influence of ideological commitment and policy-making on the provision of health care and challenges the assumption that high-quality care for all citizens requires massive financial investment. The evolution of the Cuban health care system since the revolution thus has implications for the U.S. health care system; specifically, it suggests that the equitable distribution of health care services in the United States requires a national health insurance and service delivery system.”

    “At TEDMED we found that using our smartphones and the clinical devices actually improved our ability to engage with the “patient,” because we were able to share and explain the physical exam findings directly at the point of care.”

    Cuba has found what “engage with the patient” really is – and without our high cost and high tech wiz bang machines.

  12. Excellent post, Shiv! A few thoughts from a non-clinician:

    *It seems that the devices can be split into two categories: those that can (and should!) conceivably be used by a layperson at home – the iHealth scale, the Withings BP cuff, and the SpiroSmart – as part of the Quantified Self/Automated Hovering movement, and those that… can’t; the others seem more appropriate, and more useful, for clinicians only. Are you of that mind, too, and if so, how does that affect how you select devices to include? Or do you think we’ll see a convergence (i.e., most/all would be appropriate for layperson use at home, if they see it beneficial to shell out the money)

    *Echoing Karan a bit, I would think that most of these devices are less “powerful” (in a broad sense) than their less-mobile counterparts, and, as a result, would be more useful in a house call than a clinic. Is that the case? Do you think this is just a classic example of disruptive innovation, and that over time they’ll be just as “powerful” as the standalone pieces I could find in my doctor’s office today – and, in fact, will take out the competition?

    *These devices – and many more, I’m sure – have significant, powerful implications for global health, and how health care is practiced/delivered in low-resource settings. Would love to discuss more with you.

    Also, check out Asthmapolis (www.asthmapolis.com) – not sure if it fits your inclusion criteria exactly, but it’s wroth taking a look. Great work! Keep it up!

  13. Great post!!!!! A smartphone instead of stethoscope in the future shows the improvement in today’s technology but how far that workouts in the medical field only matters. …….It is a very good idea to adopt to this new technology but with certain limits……Keep sharing

  14. Hi John, I agree that careful scrutiny is required as with all medical devices, and not everything that shines is gold. Tablets do have longer battery lives, but would be awkward to attach to devices such as the otoscope and ophthalmoscope. Images can always be sent to larger monitors or, as we were doing at TEDMED, broadcast in real-time via AirPlay.

    Regarding bedside pcr I’ll take you up on that! Spartan Bioscience has a bedside PCR that does point-of-care analysis within an hour (http://www.spartanbio.com/). Last year the RAPID GENE study was published in the Lancet detailing its pharmacogenomic use to predict clopidogrel efficacy (http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60161-5/abstract). Another company, Biomeme, aims to develop a smartphone-based PCR system (http://bio-meme.com/).

    As whole genome sequencing decreases in price, what /may/ happen in our lifetime is universal sequencing at conception starting with children born in developed nations in the 2020s. Now we just have to make sense of the data…:)

  15. That’s a great question. It will be up to manufacturers to do the initial training of clinicians and then for clinicians to train their patients on how to collect data accurately (eg AliveCor) as well as direct them to training resources. Fortunately many of the devices are fairly straightforward or have instructions built into the app. Eg when you plug in the BP cuff it walks you through the steps to getting an accurate recording. Videos like the one about the iExaminer are also extremely clear and allowed laypeople I’ve shown the device to to take very good fundus image within an hour or trying.

  16. Hey Shiv,

    Love what you’re doing (here and elsewhere)!

    I recently learned about at-home sleep studies (http://online.wsj.com/article/SB10001424127887324715704578480883962087110.html), and the tradeoffs there came to mind when reading your post. For example, at-home sleep monitoring is good at catching moderate/severe sleep apnea, but misses mild cases—specific, perhaps, but not very sensitive. If you strongly suspect severe sleep apnea, it seems much more economical and convenient than sending a patient to a lab. If your judgment says the patient is borderline, might be better to go with the lab.

    I wonder if similar tradeoffs apply with these products. For example, the smartphone EKG is great, especially in emergencies, but a 12-lead system captures stuff that a single lead simply wouldn’t.

    I bring these up because I’m very interested in how we could synthesize the evidence on these to determine when a “smartphone” approach fits best, and when the old-school methods are the way to go. Sort of how we’ve determined that, in disease screening, it’s best to start with something sensitive (eg ELISA) and then confirm with something specific (eg Western Blotting).

  17. 1) My clinic recently started doing audiometry testing with a smartphone-based clinical device. It saved us a lot of money over traditional audiometry devices and works just as well.

    2) I don’t have any specific suggestions, but in addition to cost savings and “data availability” considerations, I would strongly recommend adopting smartphone-based devices only if they duplicate the function of a proven physical examination component. There’s a tendency to think “more data is better” when it comes to the physical, but in fact more data can significantly complicate interpretation/diagnosis (put another way, more data does not equal more actionable information). To harp again on carotid artery imaging, this has not been shown to improve clinical outcomes when applied routinely (i.e., indiscriminately), and there’s little evidence that “a picture is worth a thousand words” in terms of images of atherosclerosis motivating patients to make positive health behavior changes.

  18. Fascinating. And I’m super jealous you got to go to TEDMED. One idea I have had for some time is to have pre-op, intra-op, and post-op anesthesia records on portable devices like iPads, that you can sign into at the beginning of the day and use all day. As it now stands you have to physically be at a computer station to enter any data and each time you go to a computer you have to sign in again. I’m told that isn’t possible because of security concerns, i.e., if you put your device down someone else could pick it up and use it for nefarious purposes. Anything like this in the pipeline?

  19. Already use a 12″ screen slate device in the exam room when seeing patients, which has a larger screen, faster processor, and longer battery life, than currently-available smartphones. Trying to find a fix for a problem that does not exist is a waste of resources. Many of the elderly patients who have eyesight problems will not be able to visualize the small smartphone screens nowadays anyway.

    Smartphones have their role, but not yet in the exam.

    I also echo Whatsen’s sentiment re: med mal lawyers. The precision, accuracy, and applicability of these smartphone accessory devices will need to be very carefully scrutinized.

    Bedside PCR? Not in my lifetime. Anyone care to wager?

  20. Think there might be a way for clinician-patient training to be coordinated? Wonder if this would help to curb some of the possible disconnect. What might such a model look like?

    Obviously with current medical students, those completing graduate medical educations–these things can be coordinated within various programs.

    Then there are practicing clinicians-hospital affiliated and private.

    Standardization might be tough…

  21. Hi Whatsen, 7 of the 10 devices have been FDA approved and the other three are pending approval. The power of these devices is that they can improve ambulatory data collection (but not interpretation, yet) and clinician-patient engagement during a clinic visit. As with any medical technology it’s important for clinicians and their patients to recognize the limitations.

  22. I will be sure to alert the med mal lawyers for whom I consult about this new wrinkle for med mal suits. I can not wait for the opportunity to assist in a suit v vendor of one of these insufficient gadgets.