The Doctor Is In (Your Pocket): When Your Smartphone Takes Care Of You

Introduction:

Mobile apps and wireless devices could revolutionize health care, transforming everything from how hospitals function to how a diabetic monitors his or her glucose level more effectively.

Adam C. Powell and John D. Halamka examine the promises and the pitfalls of the mobile health care revolution.

Adam C. Powell, Ph.D. is a health care economist and president of Payer+Provider Syndicate.

According to the National Institutes of Health, mHealth is “the use of mobile and wireless devices to improve health outcomes, health care services and health research.” While mHealth products have slowly become more popular over the past decade, the proliferation of smartphones means they are poised for adoption by the vast majority of Americans.

For the first time in American history, it is common for people to run around with wireless radios capable of transmitting data across personal networks, local networks and global networks. Every day, people are carrying all sorts of sensors: accelerometers, compasses, GPS devices, gyroscopes, and cameras. But, from a health care perspective, these tools often go to waste because we have not found the right way to create programs and products that are useful to actual people.

Many mHealth products don’t work because they require behavioral change, and changing behavior is hard.

The first major challenge that mHealth products face is social: how to develop human-centered products that account for the realities of human behavior. Many mHealth products don’t work because they require behavioral change, and changing behavior is hard.

If a morbidly obese patient has to weigh himself daily, record that weight, and transmit that record to his doctor, that’s three new behaviors (none of which is enjoyable). Instead, why not embed a Wi-Fi chip in a scale to record and transmit the weight automatically? The scale could then be programmed to send a reminder to the patient’s cellphone if he forgets to weigh himself.

Successfully managing chronic diseases often has little or no immediate benefit to the patient. Sometimes, as with side-effects from lifesaving medications, the patient feels worse.

But, humans are programmed to prioritize short-term benefits over long-term benefits. To overcome this, some mHealth apps and devices provide people with both immediate and long-term rewards (and penalties) for their actions. By fining people for not exercising or beeping until a medication is taken, these tools provide the short-term prods people need to eventually see long-term benefits.

Even as mHealth tools are overcoming social challenges to their acceptance and use, a host of legal challenges remain. Apps can become dangerous. There are a number of apps that claim to be able to measure heart rate using a phone’s camera. What if they are wrong? What if they say my heart rate is normal, but it’s not? What if they say my heart rate is not normal, but it is? What if I make medical decisions based on their findings?

As a result of the developing regulatory clarity, we’re about to see the professionalization of mHealth.

The regulation of mHealth apps is a work in progress. The FDA’s first approval of a medical app was at the beginning of 2011. By the first quarter of 2013, the agency had approved over 100 medical apps. The FDA showed its teeth for the first time in second quarter of the year by launching an inquiry into an app that had not received approval. While FDA action has been rare, it has been real.

The FDA is taking a risk-based approach to regulating medical apps. The FDA’s recent guidance states that it is regulating apps that act as medical devices or are accessories to medical devices more closely than apps that pose minimal risk: e.g., those that help patients manage conditions or communicate with their health care providers.

As a result of the developing regulatory clarity, we’re about to see the professionalization of mHealth. We’re going to see more users, bigger investments into app development, and an expectation of quality.

John D. Halamka, MD, MS, is chief information officer of Beth Israel Deaconess Medical Center and chairman of the New England Healthcare Exchange Network.

About 27 percent of patients in the greater Boston area have medical records at both Partners HealthCare and at CareGroup. Both hospital groups have had electronic medical records for decades. Yet until recently we couldn’t even send electronic records across Longwood Avenue, let alone across the country.

That situation is changing rapidly. Over the last four years we’ve spent nearly $20 billion as a nation on health care information technology. Incentives in the Affordable Care Act are speeding the transformation of how we record, save and use data to provide better care to patients.

We had reporters calling my IT staff, trying to get passwords to access our medical records.

The ease of transmitting data electronically raises new challenges of keeping data private and secure. Here are two recent examples from my hospital:

1) I am the steward of the medical records of both suspected terrorists in the Boston Marathon bombings. When that event occurred on Patriots' Day, 24 victims came to Beth Israel Deaconess Medical Center for care, as did both the Tsarnaevs.

We had reporters calling my IT staff, trying to get passwords to access our medical records. To make sure that authorized internal users didn’t misuse their access, we had to modify a number of our systems to flag who was looking at what records. Coordinating care and sharing medical data, while protecting that data from both internal and external abuses is a challenge, but it’s one we’re meeting.

2) Dr. X (not his real name) goes to an Apple store, buys a new mobile device. He goes back to his office and promptly downloads 119,000 emails onto the device. That's a problem in itself.

One of those emails contains a PowerPoint presentation. That presentation contains a chart. That chart reveals a spreadsheet with 4,000 patient names and their medical diagnoses. That’s a bigger problem.

Dr. X leaves his device on his desk, goes to a meeting, and when he comes back, the device is gone. A known felon had walked into the building, picked up the device and walked out with it. We had him on videotape and the police arrested him; but by that point the device was gone. That’s a material breach of privacy.

As of Sept. 23, we have a new federal regulationthat imposes a $1.5 million fine on a health care institution for “material breaches of privacy” like the one involving Dr. X earlier this year.

In the eyes of the Office for Civil Rights (which enforces this HIPPA regulation), as the chief information officer for the Beth Israel Deaconess Medical Center, I'm accountable — for every byte of data that flows through our networks for every patient who comes to see us. That’s why I — along with every other health care CIO in the country — am working to upgrade our technology and to train our staff to use it properly.

What I hope happens is that we develop a "learning health care system." For example, a couple of years ago Beth Israel-Deaconess worked with local insurers to develop a computer system to authorize X-rays and MRIs. This means no more phone calls from doctors to insurance call centers to argue over which tests were appropriate for a patient, and therefore which tests the insurers would pay for.

Every time there's effective innovation anywhere in our health care system, that knowledge should be shared across the country.

Everyone saves time and money. Not only did it eliminate the phone calls (and the administrative costs that went with them); it also resulted in a 15 percent decrease in the number of radiologists on our staff, because we eliminated so many unnecessary and redundant tests.

This system shouldn't be a Beth Israel Deaconess asset. It should be a national asset. Every time there's effective innovation anywhere in our health care system, that knowledge should be shared across the country.

mHealth is a way for patients to access to all this information. With our infrastructure in place, with the incentive to keep patients well, with payment models that are looking at prevention as opposed to sickness, we are standing on the edge of a truly innovative era in medicine.

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