There is a corner of the health care industry where rancor is rare, the chance to banish illness beckons just a few mouse clicks away and talk revolves around venture deals, not voluminous budget deficits.
Welcome to the realm of Internet-enabled health apps. Politicians and profit-seeking entrepreneurs alike enthuse about the benefits of “liberating data” – the catch-phrase of U.S. Chief Technology Officer Todd Park – to enable it to move from government databases to consumer-friendly uses. The potential for better information to promote better care is clear. The question that remains unanswered, however, is what role these consumer applications can play in prompting fundamental health system change.
Michael W. Painter, a physician, attorney and senior program officer at the Robert Wood Johnson Foundation, is optimistic. “We think that by harnessing this data and getting it into the hands of developers, entrepreneurs, established businesses, consumers and academia, we will unleash tremendous creativity,” Painter said. “The result will be improved and more cost efficient care, more engaged patients and discoveries that can help drive the next generation of care.”
The foundation is backing up that belief with an open checkbook. RWJF recently awarded $100,000 to Symcat, a multi-functional symptom checker for web and mobile platforms. Developed by two Johns Hopkins University medical students, the app determines a possible diagnosis far more precisely than is possible by just typing in symptoms as a list of words to be searched by “Dr. Google.” Symcat also links to quality information on different providers and can even direct users to nearby emergency care and provide an estimate of the cost.
Doctors wanting to determine a patient’s atrial fibrillation burden have a myriad of technologies at their disposal: 24-hour Holter monitors, 30-day event monitors that are triggered by an abnormal heart rhythm or by the patient themselves, a 7-14 day patch monitor that records every heart beat and is later processed offlineto quanitate the arrhythmia, or perhaps an surgically-implanted event recorder that automatically stores extremes of heart rate or the surface ECG when symptoms are felt by the patient. The cost of these devices ranges from the hundreds to thousands of dollars to use.
Today in my clinic, a patient brought me her atrial fibrillation burden history on her iPhone and it cost her less than a $10 co-pay. For $1.99 US, she downloaded the iPhone app Cardiograph to her iPhone.
Every time she feels a symptom, she places her index finder over the camera on the phone, waits a bit, and records a make-believe rhythm strip representing each heart rhythm. With it, comes the date and time.
I read a few months ago that the number of available iPhone apps had exceeded a million, with new apps now appearing that are intended to help sort through the mountain of other apps. We have reached the age of meta-apps.
Parenthetically, I have always loved that “meta”concept. In college, when people asked why I majored in philosophy despite the fact that I was pre-med, I explained that my intention was to become a metaphysician.
In any case, there are now many thousands of medical apps, and the number seems to be growing arithmetically! (Perhaps it was exponential at first, but I suspect the viral replication phase for apps has peaked, so anyone who uses the term exponentially at this point probably needs to review their 8th grade algebra.) In spite of this seeming plethora of handy apps, there are still a few I have yet to encounter and would like to see created, although I will probably receive some comments on this post alerting me to the fact that some of what I am looking for has already been produced.
So here are, in no particular order, 7 apps I would like to see:
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.
As an ever increasing amount of money seems determined to chase an ever greater number of questionable ideas, it’s perhaps not surprising that inquiring minds want to know: (1) Are we really in a tech bubble? (2) If so, when will it pop? (3) What should I do in the meantime?
I’m not sure about Question 1: I’ve heard some distinguished valley wags insist we’re not in a tech bubble, and that current valuations are justified, but I also know many technology journalists feel certain the end is neigh, and view the bubble as an established fact of life – see here and here. The surge of newly-minted MBAs streaming to start-ups has been called out as a likely warning sign of the upcoming apocalypse as well.
I have the humility to avoid Question 2: as Gregory Zuckerman reviews in The Greatest Trade Ever, even if you’re convinced you’re in a bubble, and you’re right, the real challenge is figuring out when to get out. Isaac Newton discovered this the hard way in the South Sea Bubble, leading him to declare, “I can calculate the motions of heavenly bodies but not the madness of people.”
I do have a thought about Question 3, however – what to do: reconsider digital health — serious digital health.
Here’s why: Instagram and similar apps are delightful, but hardly essential; most imitators and start-ups inspired by their success are neither. It doesn’t strain credulity to imagine investors in these sorts of companies waking up one day and experiencing their own Seinfeld moment, as it occurs to them they’ve created a portfolio built around nothing.
It didn’t appear on the lightning strike map, but lightning did indeed strike a young medical student inside the Washington Convention Center right in front of about 1,500 amazed spectators on the first day of The Health Data Initiative Forum III: The Health Datapalooza. Everyone is fine—though our medical student may never be the same again.
Actually, this story began long before Datapalooza, of course. Fourth-year medical student, Craig Monsen, and his Johns Hopkins Medical School classmate, David Do, started collaborating on software applications soon after they met in first-year anatomy class. Craig graduated from Harvard with degrees in Engineering and Computer Science and David from University of Minnesota in Bioengineering.
They’re not quite Jobs and Wozniak—neither dropped out of anything—yet—although Craig, at least, is planning to skip or delay residency. You see, after seeing the Robert Wood Johnson Foundation (RWJF) Aligning Forces for Quality Developer Challenge last year—they got very serious about bringing to life their vision of new applications that could help patients and consumers make great health care decisions.
For the majority of my career I have been obsessed with creating technologies to modernize our largely dysfunctional U.S. healthcare system. To me, it is very clear that the emergence of cloud computing has finally created the opportunity to truly address this daunting problem. Cloud-based solutions are the only viable option for effectively getting providers, patients and other key stakeholders online so that the necessary efficiencies find their way into the system.
To the rest of healthcare IT, however, it is not so clear, as witnessed by the lack of truly cloud-based companies in the marketplace.
Most of the large, established players in this industry continue to rely on the outdated client/server or older technologies, such as MUMPS. Some of these companies’ products trace their roots as far back as 1969. These companies and their software were built before the world wide web, before Facebook, the iPhone and iPad, salesforce.com – and even email, for God’s sake! There also exists a tremendous amount of confusion related to the morass of small, bootstrapped EMR companies, which number in the hundreds. People do not understand the difference between buying a monolithic single-purpose app to utilizing a robust, cloud-based platform approach.
This lack of understanding has made me realize that we need a better way to explain what the cloud has the power to do, and what true cloud-based technology even is. Easier said than done!
I was recently afforded a breakthrough, though unfortunately at the expense of an ancient treasure. Allow me to explain:
Reviewing “The Myth of The Paperless Office” for the New Yorker in 2002, Malcolm Gladwell argued that if the computer had come first, and paper didn’t exist, someone would have had to invent it. Paper, it turns out, is a lot more useful than we typically appreciate.
It occurred to me that perhaps the same might be said of another product we seem to take for granted in the digital age – medicines. (Disclosure: I work at a company that makes them.)
Medicines – you know, those little white pills that everyone loves to critique – are in many cases remarkably effective solutions to very difficult problems; it’s actually kind of amazing how useful some of these products can be. What an incredibly powerful idea – addressing a difficult and complex health problem with a simple pill you can pop before breakfast.
I read a tweet recently asserting that physicians may soon prescribe health apps as an alternative to medications; my initial reaction: good luck with that one. It’s certainly easy enough to envision how magical thinking about the power of health apps will soon be replaced by disappointment as app developers realize something drug makers have known for years: it’s hard to improve health, and it can be very difficult to get patients to stick with a treatment long enough to make a difference.
Despite a constant buzz around the idea of using mobile technologies for patient engagement, the depth and breadth of these solutions has remained consistently thin and frankly dated. Today, healthcare organizations who are adopting and deploying engagement solutions are focusing these efforts on marketing/patient retention (e.g., simplifying transactional processes such as appointment scheduling, prescription refills, etc., online access to lab results & records) and accelerating payments (online bill-pay). Despite all the talk about using mHealth for care provisioning, our research for the upcoming report that will be released later this month, mHealth Adoption Trends for Provider-Patient Engagement, finds a market that is still in an early, embryonic stage of development.
So why the disconnect between the hype of mHealth for care provisioning and reality? Of the many potential reasons, there are two that are dominant: a lack of solutions with proven clinical efficacy and few financial incentives to drive adoption.
While there is little argument that increasing the interaction between a care team and their patients is a good thing, the best means for accomplishing this feat are still unclear. A year ago, Group Health published results from an internal study testing just what impact this increased communication may have on outcomes and patient satisfaction. What they found comes as no surprise to us as trusting advocates of patient engagement. In this study, Group Health provided patients suffering from depression a relatively simplistic form of engagement wherein patients were able to communicate with their care team through the EMR portal. The results, impressive: antidepressant medication adherence increased 33%, overall depression scores decreased, and satisfaction with treatment improved 61%.
The use of cell phones by community health workers and other medical practitioners in low-income countries has been promoted as a potential revolution for health systems development. This “mHealth” revolution has been seen as an opportunity to develop diagnostic, treatment and surveillance networks wirelessly, to build mobile apps allowing remote nurses and doctors to provide higher-quality care to rural patients even in places without a hospital or well-functioning health clinic. Several foundations are now offering grants to build and distribute phone applications that will offer everything from prescription drug advice to epidemic surveillance tools. But is mHealth really going to improve health outcomes? Or is it just another technological bomb thrown at poverty and poor infrastructure?
Globally, about 3.1 billion people used mobile phones in 2007; that’s nearly half the planet. The greatest growth during the last decade has occurred in Asia, the Middle East, and Africa. In many of these continents, mobile phone subscribers outnumber fixed-line telephone subscribers, particularly as countries leap-frog over the traditional development step of planting land-lines and rely instead on building wireless communication towers and Internet-based businesses.