• Color me skeptical about mHealth

    When I was a medical student, my then-girlfriend (now wife) bought me this amazing device called a Palm Pilot. The thing was amazing. When I was a resident, I taught myself to program for the things. I even helped to start a small software company making medical programs for handheld devices. I thought these things would change the way we practiced medicine.

    I was so convinced, I dedicated my fellowship to studying their use in the NICU. I created an EMR that was Palm OS based and conducted a randomized controlled trial to see if if could reduce documentation errors. It pretty much didn’t work.

    Later, I did a number of studies looking at mobile technology to improve adolescent diabetes management. I’m talking over the course of years. Again, modest results, but nothing to set the world on fire.

    I bring this up to say that I’m a huge supporter and believer in mobile technology. But I’m realistic about how far we’ve got to go to make it work well.

    There’s a Viewpoint in JAMA this week on the topic that starts a bit too optimistic for my taste:

    There is substantial enthusiasm for the concept of mobile health (mHealth), a broad term typically used to describe the use of mobile telecommunication technologies for the delivery of health care and in support of wellness. In 2011, US Secretary of Health and Human Services Kathleen Sebelius referred to mHealth as “the biggest technology breakthrough of our time” and maintained that its use would “address our greatest national challenge.” This level of exuberance for mHealth is driven by the convergence of 3 powerful forces. First is the unsustainability of current health care spending and the recognition of the need for disruptive solutions. Second is the rapid and ongoing growth in wireless connectivity—there now are more than 3.2 billion unique mobile users worldwide—and the remarkable capability this brings for the bidirectional instantaneous transfer of information. Third is the need for more precise and individualized medicine; a refinement in phenotypes that mandates novel, personal data streams well beyond the occasional vital sign or laboratory data available through intermittent clinic visits.

    Towards the end, they have a little more equipoise:

    mHealth technologies have the potential to change every aspect of the health care environment and to do so while delivering better outcomes and substantially lowering costs. For consumers, mHealth offers the promise of improved convenience, more active engagement in their care, and greater personalization. For clinicians, mHealth could lead to reduced demands on their time and permit them to instead refocus on the art of medicine. Much remains to be done to drive this transformation. Most critically needed is real-world clinical trial evidence to provide a roadmap for implementation that confirms its benefits to consumers, clinicians, and payers alike.

    Worth reading in full, but I leave you with this. For decades, people have been promising us that health information technology would revolutionize the health care system. I’m still waiting.

    @aaronecarroll

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    • I’ve commented before about the coming (and it’s coming) revolution in the use of wireless monitors. Who doesn’t want 24/7 medical care? I’m involved in its development in the civilian sector (for capnography), and I can say that many physicians are opposed, very opposed, to this. Their objections are similar to what’s expressed by the cleaning lady in that Doonesbury cartoon Dr. Carroll linked last year (and Frakt alluded to this morning). .

    • It’s interesting that we group everything together in the same grouping — mobile health, health IT, etc. — because as best as I can tell, a piecemeal approach works. (I saw a meta-analysis concluding that, for fall sensors, wearable sensors work…and bed sensors do not.) So we’re likely to see piecemeal advances and steps back.

      I’m somewhat bullish about the sector. The joke about IT is that its effects have shown up everywhere but the productivity statistics; I think we might see a similar path where we steadily figure out what works and what doesn’t until it all adds up. It won’t be the same wildfire adoption as we’ve seen in media.

    • Ilas struck by RA’s comment…

      “Who Doesn’t want 24/7 medical care?”

      One thing that I have struggled with is that we see very little discussion of consumer segments in the back and forth on the ACA and health issues in general…

      But they exist – and they differ widely on what they want from HC and how they relate to providers…

      So I went on a search for something in this area – surly someone has done something in this area.

      They have – an interesting study by Deloitte…

      **http%3a//www.deloitte.com/assets/Dcom-UnitedStates/Local%2520Assets/Documents/us_chs_InfoBrief_2012HealthCareConsumerSegments_011813.pdf

      In the end – the mHealth stuff will have some value – but not as much for some segments as it will with others.

      Success will depend on the kind of things marketers know about – and do all the time – targeting the right segment – and positioning the product/service the best way.

      But my observation as an outsider is that the Health Care industry is not very good at this sort of thing – the tendency is to try and apply things universally – and a look at the Deloitte study tells me that this is not a very good idea.

    • I work for a DOD-affiliated research program that started deploying mHealth tablets for research purposes (capturing data while conducting exams and study visits), and it’s been a tremendous tool in increasing our efficiency and accuracy.

      It definitely takes considerable time, effort, and some seed money to get the system up and running, but the ability to get data back for analysis (especially in clinical drug trials) quickly seems to be well worth it. Docs and research coordinators can take the tablets with them all day while they conduct study visits. They just input the clinical data into the tablets using either the tablet keyboard or a stylus (using handwriting recognition to change their scribbles into actual data in real time) and they’re done.

      We don’t need to send paper case report forms for double data entry, all the queries can be done in real time as they’re capturing data, and they have the previous visit records when they need them.

      Of course you can overstate just how transformative mHealth will be (it’s far from “the biggest technology breakthrough of our time”), but for medical research at least mHealth has strong potential to make care and research safer, more cost effective, and more time efficient.

    • My thought here is that it’s not technology, but process, that’s important.

      For example, it sounds to me that approaches such as that in “The Checklist Manifesto” will make real improvements in medical care. I know it’s boring, but delivering plain, ordinary, uninspired, garden-variety medical care correctly and reliably, without operating on the wrong kidney, sounds real important to me. That is, looking for actual problems and figuring out something that actually fixes them is more likely to actually make things better than throwing technology around because it’s “obvious” that, e.g. computers are better than paper.

      That said, I really like it that my GP here has my whole medical history at his fingertips and can (and does) scan through it easily. I saw him today to get my BPO meds refilled (Japan insists you see your doc to get meds refilled; there are no refillable prescriptions here), and mentioned that my vision problems turned out to be due to an easily fixed “secondary cataract”, a problem that was new to him, but he pulled up an article on it right there during the visit. (I mention this as an example of technology working, NOT Japan getting it right. At least this time.)

    • I’ll tell you where technology is going to make a difference: big data looking at health information. My machine learning friends say that machine learning systems could be better than radiologists at reading mammograms right now, if health care systems would allow access to the digital mammograms and health data to set up the systems. (Big data means 200,000 mammograms, not 2000).

      And there are a lot of other issues where big compute power looking at lots of health data would come up with good answers about treatments and diagnoses.

    • Put me down as a skeptic as well. There are definitely some benefits that technology can deliver, but overall I just see a lot of tech people who know little about health care and how it’s delivered getting real excited about how they’re going to transform an industry they don’t understand.

      That said, there are some interesting apps for individuals out there that might help with, for example, drug adherence. So the potential is there, but of course I’d rather see it driven by patient and provider demand, not the best and the brightest sitting in DC trying to figure out how EMRs should be designed.