Should Docs Prescribe Data?

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I’ve always been a little skeptical of the push to get doctors to prescribe apps.

To begin with, it would be awfully easy for us to replicate the many problems of medication prescribing. Chief among these is the tendency for doctors to prescribe what’s been marketed to them, rather than what’s actually a good option for the patient, given his or her overall medical situation, preferences, and values.

Then there are the added complexities peculiar to the world of apps, and of using apps.

A medication, once a pharmaceutical company has labored to bring it to market, basically stays the same over time. But an app is an ever-morphing entity, usually updating and changing several times a year. (Unless it stops updating. That’s potentially worse.)

Meanwhile, the mobile devices with which we use apps are *also* constantly evolving, and we’re all basically forced to replace our devices with regularity.

Last but not least, how can we know the benefit of prescribing one app compared to another? Studies are few and far between. And by the time a study is published, everything – the app, people’s use of technology, the mobile devices, the sensors – will have gone through several phases of change. This means we generally won’t have much of an evidence base, when it comes to the prescribing of a given app.

All of this means that it would be a Herculean task for physicians to maintain enough current knowledge about apps, such that they could prescribe them in a thoughtful and informed matter.

So let’s scrap the talk of prescribing apps, and instead focus on what we really can prescribe: what a patient should track.

Why we should prescribe what to track, rather than how to track

Last year, at the Medicine X conference at Stanford, an e-patient and technologist named Natasha Gajewski asked me if I’d participate in a workshop with her. She wanted to include a clinician perspective in a workshop about patient-generated data. Like many proactive patients, she’d found that doctors were not always receptive when she tried to share her health tracking data with them. (For an excellent scholarly commentary on how different healthcare stakeholders view data, read this.)

The workshop was fun: we sat at tables, mixing patients, clinicians, and technologists, and we shared our varied perspectives on patient-generated data.

The patients were, of course, fairly proactive e-patients. They had compelling stories about why they want to track data, how their tracking effors had helped them, and why they want to share it with their doctors.

As for the clinicians, we talked about what it’s like to get data, especially when you didn’t request it, or when it arrives as reams of information in a difficult format (e.g a long scribbled list of BP readings). We also talked about the difficulty of getting patients to track when we ask them to. After all, the average patient attending MedX is generally more motivated and tech-oriented than the average patient in primary care clinic. Ever asked a patient to keep track of their sleep, or incontinence episodes, or shortness of breath episodes, or even use of their PRN pain medications? It’s often not so easy to get the info you need in order to help them.

Based on our conversation, we came up with the following key points:

  • Gathering patient data between healthcare encounters is very valuable. It doesn’t really matter what the health problem is. Especially if it’s related to symptoms or biometric data (e.g. blood pressure), we’re better off having more data to review. The days of relying on an occasional office-based measurement, or of digging symptom data out of a patient’s memory, should be over.
  • Apps and new technologies have great potential to help patients gather data. This is a no-brainer. We did talk about how it’s important for the data-gathering process to be very user-friendly for the patient; the less effort and friction, the better. We also talked about ensuring that the data-measuring device is accurate and precise.
  • The goal of healthcare encounters is for clinicians to use their medical expertise to help a patient reach his or her health goals. In other words, healthcare – and patient engagement — should be based on the idea of collaboration. In general, patients are experts on their goals (and their symptoms), and clinicians are supposed to be experts in interpreting medical information and recommending management approaches.

Ergo: Clinicians should advise patients on what data to track, to help address a given health problem.

There are number of advantages to this approach. To begin with, it’s good use of a clinician’s medical expertise. If a patient is concerned about sleep problems, we clinicians can advise them as to what sleep — and non-sleep — data will help us help him. If a patient has atrial fibrillation and complains of shortness of breath, we can explain why tracking her pulse would be helpful.

Also, if a clinician gets to weigh in on what kind of data to track, then presumably that clinician will be ready and receptive when a patient does start sending in data.

Best of all, specifying what is medically most useful to track does not require keeping up with ever-changing apps and technology.

In other words, it’s feasible and doable for clinicians.

This doesn’t mean we’re entirely off the tech hook, however. Many patients will want suggestions as to how to track, and the more specific guidance we can provide, the more likely it is that they’ll get the job done.

Also, as clinicians we have a definite stake in how that data gets back to us, and is presented to us. Most of us don’t want to be incessantly pinged regarding an incoming data point. Although the healthcare system should be more continuously attentive to patients, clinicians will need to keep thinking about each patient episodically.

And when it’s time to think about the patient and her data – whether that’s because it’s time for the scheduled follow-up, or because a worrisome data point has generated an alert – we clinicians will want it to be as easy as possible for us to access the data, review it, and do our medical work based upon it.

How you can manage the prescribing of tracking: a cool tool born at MedX

Let’s say we’re good 21st century clinicians and we want to collaborate with our patients and prescribe some tracking. How might we actually manage the logistics?

It turns out there is a very nifty tool now available for beta-testing: Open mHealth’s Linq Platform.

Did I mention that Dr. Ida Sim, a co-founder of Open mHealth and a general internist, was there at that MedX workshop last year?

Fast-forward to this year’s MedX. During a session on improving doctor-patient communication, Ida gave a talk titled “BYO App: Bridging the Gap Between Patients & Clinicians.” She had turned the workshop conversation about patient-generated data into a real working product: a platform that enables doctors to “prescribe” some form of data tracking, and receive that data in a usable format.

True to the spirit of Open mHealth, Linq is meant to integrate data from a variety of apps and devices. The platform itself gives clinicians a way to invite patients to track and share data, while giving patients the flexibility to choose tracking methods that work well for them.

To learn more about Linq, which is now being beta-tested in Stanford’s Preventive Cardiology Clinic, take a look at Ida’s presentation on Slideshare.

Like any new product, it’s surely not perfect. But I think it’s a great direction for us to take, when it comes to doctors using patient-generated data to help people reach their health goals.

Of course, we’ll still need to collectively ensure that patients get the help they need choosing an app or device for a given tracking need. But that doesn’t need to be the doctor’s job. Just as the ideal clinic has a pharmacist available to counsel patients on medications, primary care teams could offer access to app specialists, who would be trained to help patients and families select and set up a tracking system.

And then we doctors would be freer to focus on what’s most important: applying our medical expertise and our human presence, in the service of helping patients reach their health goals.

Leslie Kernisan, MD MPH, is a practicing geriatrician, cautious techno-optimist, and enthusiastic caregiver educator. She looks for useful tools & innovations that can make great primary care available to all older adults. She is a frequent THCB contributor, and blogs at Geritech.org and atGeriatricsForCaregivers.net.

7 replies »

  1. What a delightful story, I love it!

    Remarkable that her GP was so proactive about tracking her BP after the med change…far too often we tell people that we’ll just see them in 3-6 months.

    And wonderful that your mother liked being involved in this…suspect many older adults would be receptive to more involvement, as long as it felt doable. People often like purpose and partnership.

  2. very interesting information, some interesting things here I would not had considered unless I was shown

  3. All so true! And so much depends on the individual patient – including the most frail, poor or elderly.

    Several years ago (before apps & other digital saviors!) my mother’s GP started a trial of new BP meds for her. He gave her (at that time frail, elderly and with signs of early dementia) two bright pink week-at-a-glance calendar pages (the kind you’d rip off a magnetic pad on your fridge) and asked her to record her BP each day and then write down the date, time of day, and BP reading – and then bring back this list after two weeks.

    My mother loved this “research” assignment that she and her her doctor were “working on”. Other than the home BP monitor (which we’d bought for her years earlier but that she’d almost never used) this was a super low-tech way to monitor patient data for a short period of time. Had she not owned a home BP monitor, using the BP monitors at her neighbourhood pharmacy would have been a good alternative (and many of these spit out a written results slip with each reading). Within days of starting this “homework”, my mother (who could never have been described EVER as an “engaged patient” until this point) could already tell that her BP #s were settling down significantly compared to when she was on her former meds. Her daily blood pressure reading announcements became her “news” on the phone every time we chatted for two weeks. She proudly presented her BP list at her next GP appointment. My mum loved her long-time GP and really liked that she was somehow “helping him” with this project! Interestingly, long after those first two weeks of pink pages had been handed in, my mum continued to test her BP almost every day afterwards until her dementia forced a move to a longterm care home.

  4. hi Carolyn, thanks for this thoughtful comment.

    Yes, the e-patients at the conferences are outliers. My main concern is that we need for innovators to hear from more of the “usual” patients, especially the older ones and sicker ones and poorer ones who are in most urgent need of help.

    In terms of tracking and data, I would say the problem is that primary care overall really doesn’t support effective collaboration between patients & clinicians, and also doesn’t support clinicians in doing what they need to do to help patients.

    Almost every time I talk to a patient and/or family, they ask for help with an issue for which I need data/information: pain, sleep, falls, incontinence, medications…I could go on and on.

    We spend a lot of time trying to dig the information we need out of people’s memories. That’s something we need to do less of.

    So I think ultimately data and tracking will be helpful, but it’s important to start with the end in mind, and make sure the partnership is going before pouring lots of extra data into the mix.

    Of course, so far there has not been a great business case for starting with good clinician-patient collaboration as the key goal…hence we have people in business trying to snarf up all the patient data they can and selling it away…not sure how to get around that.

  5. Wonderful overview of this topic, Dr. K. You raised such an important point about the patients represented by the ePatient scholars at Medicine X. They are, in essence, the outliers of the patient world: keen, smart, engaged, enthusiastic, articulate, and in most cases, already tech-savvy self-trackers (including some who are card-carrying Quantified Selfers) – as well as those who are not actually “sick” by most sick people’s definition of that word.

    Contrast that unique demographic with the poor or elderly patients who would likely benefit most from “patient-generated data” – yet are ironically least likely to have the ability/energy/will/capacity to do so. As Dr. Danny Sands, founder of the Society For Participatory Medicine, once tweeted at a similar health conference:

    “Why so many services & apps for the 1%? The users of these products are NOT the same as real patients I care for?”

    And no discussion of docs and apps would be complete without a nod to Dr. Aaron Carrol’s brilliant words in this recent Vox post “Why Doctors Do Not Want Your Fitbit Data”:

    “Research shows that over one-third of doctors have reported personally missing test results that led to care delays for their patients because they’re already overwhelmed by alerts and data. More data isn’t the answer.” http://www.vox.com/xpress/2014/8/18/6031595/video-why-doctors-dont-want-your-fitbit-data

    Trouble is, it all depends on who’s doing the selling: for many developers, more data IS indeed the only answer, and thus they’ll keep on developing solutions looking for problems.


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