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?