The nation’s ongoing battle to strike a delicate balance between increasing access to quality health care for all Americans and reducing overall health care spending just scored one of its most substantial victories.
In late April, after several months of thoughtful and robust collaboration, the Federation of State Medical Boards (FSMB) ratified a new model national policy – the Appropriate Use of Telemedicine in the Practice of Medicine – at its annual meeting in Denver.
This marks the first time the medical community has unilaterally acknowledged the impact technology has had on the practice of medicine, and the ability telemedicine — or connected health — has to facilitate and improve the delivery of health care.
Let us first put this in perspective. We all know health care is at a critical juncture. The implementation of the Affordable Care Act means millions of newly eligible Americans will seek access to an already over-burdened health care system.
The nation faces a serious shortage of primary care providers, specialty care is becoming more diversified, and access to care in rural areas is an ongoing challenge. All of these issues are on the rise.
Enter technology-enabled care. Real-time video encounters between patients and providers reverse the burden on patients to seek care in a hospital or doctor’s office by bringing health care directly to them, in their home. At the same time, remote monitoring, sensors, mobile health and other technologies are helping to reduce hospital readmissions, and improving adherence to care plans and clinical outcomes, as well as patient satisfaction.
Connected health tools also support preventative care efforts for chronic care patients and can empower individuals to make positive lifestyle changes to improve their overall health and wellness.
Momentum for telehealth is accelerating at an undeniable rate. As of March, twenty states and the District of Columbia have passed mandates for coverage of commercially provided telehealth services; 46 states offer some type of Medicaid reimbursement for services provided via telehealth.
A study by Deloitte predicts that this year alone, there will be 100 million eVisits globally, potentially saving over $5 billion when compared to the cost of face-to-face doctor visits. This represents a growth of 400 percent in video-based virtual visits from 2012 levels, and the greatest usage is predicted to occur in North America, where there could be up to 75 million visits in 2014. This would represent 25 percent of the addressable market.
I first posed the question, “Could Mobile Health Become Addictive?” on August 20th. Since then I’ve done more thinking and I’m warming to the concept.
To start with, addiction is a word laden with negative meaning. When we hear the word, we think of opiates, street drugs, cigarettes, or possibly gambling. In fact, Wikipedia defines addiction as, “the continued repetition of a behavior despite adverse consequences.” So, with that definition as backdrop, is there any way health can really be addictive? Probably not.
What I’m really talking about is the juxtaposition of motivational health messaging with some other addictive behavior, specifically checking your smartphone.
New evidence shows that people are in love with these devices, checking them more than 100 times per day! I’ve heard people are tapping in 110, even 150 times a day. Of course this varies, but let’s face it, we check our smartphones a lot and it’s hard to stop. A somewhat disturbing video makes the case well. It’s easy to build a case that smartphones are addictive.
Recent research shows that checking your phone results in a small release of the neurochemical dopamine. Dopamine release has long been associated with ingestion of addictive substances such as heroin and tobacco. In fact, once the pattern of ingestion and dopamine release is established, even thinking about the ingestion triggers the dopamine release, the biochemical explanation for cravings.
For this post and a series to follow, I choose not to question whether this compulsive relationship with smartphones is good or bad, but simply to acknowledge that it is common, almost universal among smartphone users and to ask if we can exploit it as tool to improve your health.
The medical board of the state of Oklahoma recently sanctioned a physician for using Skype to conduct patient visits. A number of other factors add color to the board’s action, including that the physician was prescribing controlled substances as a result of these visits and that one of his patients died. This situation brings up several challenges of telehealth — that is, using technology to care for patients when doctor and patient are not face-to-face.
• Legal/regulatory: On the legal side, physicians are bound by medical regulations set by each state. It appears that the use of Skype is not permitted for patient care in Oklahoma.
• Privacy/security: Skype says its technology is encrypted, which means that you should not be able to eavesdrop on a Skype call. That would seem to protect patient privacy. At Partners HealthCare, we ask patients to sign consent before participating in a ‘virtual video’ visit. Because this is a new way of providing care, we feel it’s best to inform our patients of the very small risk that their video-based call could be intercepted. I don’t know if the Oklahoma physician was using informed consent or not.
But the most interesting aspects of this case involve the question of quality of care. Can a Skype call substitute for an in-person visit? Under what circumstances?
Video virtual visits are a new mode of care delivery. Whenever anything new comes up in medicine, it is subject to rigorous analysis before entering mainstream care. That same rigor applies to video virtual visits. Although some studies suggest virtual visits can be useful, the evidence is not yet overwhelming. I can’t say with 100% certainty how virtual visits will best be used, but based on several pilot programs under way at Partners, I have a hunch or two.
We have believed for some time that this technology should be limited to follow up visits, where the patient and physician already have a well-established relationship. Technologies such as Skype and Facetime allow for a robust conversation, but most doctors’ visits require much more than just conversation. For example, any time a physical exam is required, this technology will not work well. That’s why one of our first pilot studies was to implement video technology for mental health follow up visits (as did the doctor in Oklahoma).
Our early results are promising. It seems that virtual video visits for mental health offer both the provider and the patient important benefits. For many mental health patients, it can be stressful to travel to the doctor’s office. When a patient is being evaluated for a medication adjustment, for example, they are not at their best. The convenience of having a follow-up visit from their own home can be a big lift for these patients. On the other hand, doctors often feel that the home environment is particularly relevant in sorting out mental health problems. A virtual visit allows them to, in effect, conduct a virtual house call.
The hype over mobile health is deafening on most days and downright annoying on some. So it is with some reluctance that I admit that mobile has the potential to be a game-changer in health. I’ve professed enthusiasm before, but that was largely around the use of wireless sensors to measure physiologic signals and SMS text as a way to deliver messages to patients and consumers. For several years, the industry has been awash with smartphone apps (by a recent count more than 40,000). At the Center for Connected Health, we started looking at mobile health as far back as 2008 and could not justify the excitement around smart phones and apps at that time, mostly because our patient population did not demonstrate significant enough adoption of smartphones to justify development in this area.
I felt very unpopular at all of the major conferences. I talked about our success with text messaging as a tool for engaging pregnant teens in their prenatal care and helping patients battling addiction to stick with their care plan, while others were touting the virtues of their various apps.
It’s worth noting that our primary focus at the Center for Connected Health has been patients with chronic illness. As such, we are every bit as concerned about the 85 year old with congestive heart failure as we are about the young professional with hypertension. However, across the population of people with chronic disease, smartphone adoption has lagged. I felt like our strategy was vindicated when my friend Susannah Fox published research showing that folks with two or more chronic illnesses (independent of other variables such as age and socioeconomic status) use technology in the context of their health less than others.
The world of patient care appears to be catching up to the rest of mobile. Not that I would ever endorse the irrational exuberance shown for mobile health apps in general, but some recent data points that changed my thinking are worth noting.
As we grapple with provider shortages, the surge in chronic illness and the quality to price (QPR as they say in the wine business) challenge in US healthcare delivery, it’s hard to imagine a future that does not include some sort of guideline or algorithm-driven care. As providers take on more financial risk, one common strategy involves team-based care, and the attendant increase in decision-making and care delivery by non-physician clinicians. If the je ne sais quoi feature of a quintessentially great doctor is clinical judgment and instinct, one of the challenges of this transition to team-based care is how to harness that trait and use it efficiently.
Care decisions that are unassailable at a population level (e.g., women should have regular, routine PAP smears or smoking is bad for your health) or are algorithmic in nature (e.g., titration of treatment for uncomplicated hypertension or therapy for mild to moderate teenage acne) can all be effectively reduced to guidelines. This, in turn, allows a physician to delegate certain therapeutic decisions to non-physician providers while maintaining a high degree of care quality. It is also thought that this type of uniformity of care delivery will improve the QPR too, by decreasing variability.
How do we come up with guidelines? Typically they are based on large-scale, randomized, controlled clinical studies. As is nicely articulated in a recent JAMA opinion piece by Drs. Jeffrey Goldberg and Alfred Buxton (JAMA, June 26, 2013—Vol 309, No. 24, pg 2559), guidelines are formulated based on the inclusion criteria for these trials. This process gives us comfort that guidelines are based on rigorous science — and that is a good thing. The challenge arises when we realize that individuals do not reflect populations exactly. Clinical research is much more complex than wet lab work because people are complex and indeed unique. Every clinician has had the experience of prescribing a therapy to a patient who fit guideline criteria exactly and having the opposite outcome of what the guideline predicts.
This past week, Google had its annual developers conference, Google I/O. One of the more provocative talks, called “The End of Search as We Know It,” was by Amit Singhal, who is in charge of search for Google.
The vision, as described by Amit, is that instead of typing words into a box on a website or mobile app, we will have conversations with Google, enabling a much more personalized, refined experience. The holy grail, of course, is that Google analytics become both predictive and prescriptive, serving you content that is just right for you and anticipates your needs.
It seems there is a race on now to achieve this vision. One could argue that Amazon, Apple, Facebook, Pandora and others are all in the same mode. Best I can tell, the promise these companies are floating to advertisers is that their ads will be served up to that focused slice of the population that will find their product relevant in the moment.
If you apply this thinking to healthcare, several controversies/topics come to the fore.
Is Google competing with IBM’s Watson? Undoubtedly yes. On the other hand, I’m guessing Google is disenchanted with the consumer health space after the demise of its personal health record (PHR). And IBM seems to be focused on clinician decision support. So early in the game, with respect to healthcare anyway, maybe there is not much competition. The path for clinician decision support is clear and the market obvious, whereas the path and market for consumer health decision support are blurry.
Last week we all watched in awe as the IBM computer, Watson, trounced two of Jeopardy’s finest. This event has been much heralded but it is worth stopping for just a minute to reflect on the experience of watching Jeopardy those three nights. I had no trouble rooting for Watson, feeling disappointed or embarrassed when he missed a question and chuckling when he displayed any behavior that seemed the least bit human. I knew the whole time, on one level, that Watson is a computer. On another level though, I bonded with him and felt a good deal of emotion regarding his success.
MIT Prof. Sherry Turkle recently released a book entitled Alone Together. She was also interviewed recently on TechCrunch. Turkle puts forth the view that technology is a poor substitute for interaction with a human being. However, she notes that when technologies (robots, relational agents and the like) respond to us, they push “Darwinian buttons,” prompting us to create a mental construct that we are interacting with a sentient being. This brings a host of emotions to the communication including affection. Turkle makes an argument that in the realm of human relationships this phenomenon is unhealthy for our species.
I’d like to bring in principles from behavioral psychologist, Robert Cialdini, who has authored several books on the psychology of persuasion. Cialdini offers simple tools that can be used in everyday life to persuade others to adopt one’s point of view. In doing so, he lays out solid experimental evidence that these tools are effective, in most cases without the recipient being aware. Continue reading…