Tag Archives: mhealth

Data is (Em)Power(ment) for Patients: Using Fit Bit to Impact Disease Management

For scientists and researchers who are developing new treatments for disease, Data is power.  For patients, Data can mean empowerment.  Devices that track health indicators are readily available.  These devices can track heart rate, blood pressure, blood sugar and even respiratory rate and body temperature.

This week in the Wall Street Journal, the medical applications of the Fit Bit device are explored.  The Fit Bit is a basic pedometer that tracks movement, steps taken, calories consumed and (in certain models) sleep habits.  This device is commercially available for around 100 dollars and was initially embraced by serious athletes in order to improve performance.  Now, according to researchers, these devices may be able to impact health outcomes–both inside and outside of the hospital or healthcare setting.  These impacts may forever change how physicians and healthcare systems think about managing chronic disease.

As I have mentioned in previous blogs, I firmly believe that smartphone applications for medicine are going to be a part of mainstream medical practice in the coming years.  Providers will prescribe apps just as they do pharmaceuticals.  In the case of the Fit Bit device and others like it, data obtained from physiologic monitoring can be used to assess physical fitness and progress towards obtaining specific health goals.  In several recent studies, researchers at Massachusetts General Hospital in Boston, have found that the Fit Bit users who have diabetes are more likely to have better control of their blood sugars and achieve weight loss related goals better than those who do not use the device.  Many patients with type 2 diabetes can better control their blood sugars through reduction in BMI (body mass index) and the data provided from the Fit Bit device seems to have a positive correlation with weight loss in this particular patient sample.  In the hospital setting, researchers at the Mayo clinic found that in post-operative cardiac surgery patients, the Fit Bit was able to identify patients that needed more physical therapy intervention–by tracking movement in the early post-operative days.  It is likely that by identifying and intervening early in patients who are not progressing after surgery we will be able to prevent many common complications such as deep vein thrombosis (DVT), pneumonia and other morbidities associated with lack of activity after surgery.

At this point, the FDA has no immediate plan for regulation as long as they are not specifically created to treat a particular medical condition or disease process–however, I do expect regulators to act on all types of biomedical data collection devices within the next 5 years.  According to the WSJ, the health monitoring device industry is projected to exceed 5 billion dollars in 2016–largely due to our focus on patient engagement and prevention.  Concerns have been raised as to the security of data and as to the reliability of the data generated by these devices.  As with most new medical innovations, there is still much work to be done.  We must create secure servers where patient’s data can be safely deposited (and HIPAA compliant) and easily accessed by their healthcare providers in order to provide necessary changes to care.  In addition, the patient must be able to access their own data in order to assess progress, adjust goals and optimize their lifestyle changes in order to produce better health outcomes.  Additional concerns have been raised around the legal implications of a large repository of medical and physiologic data—are physicians responsible for every reading and every piece of data in the repository?  Will there be frivolous lawsuits initiated by ambulance chasers (or Fit BIt chasers) in the future?

I contend that more data is better.  Data provides me with the power to make better decisions for my patients.  Data provides my patients with real, meaningful feedback.  When we are sick, we often feel as though we have lost the ability to determine our own destiny and lose any semblance of control.  Data allows patients with chronic illness to actually regain some sense of control—and achieve ownership of their disease with the power to invoke change.

Screen Shot 2014-06-26 at 8.25.36 AM

 

 

 

 

 

 

 

Screen Shot 2014-06-26 at 8.25.36 AM

 

 

Home monitoring to improve health outcomes: Holy grail or Rabbit Hole?

Technology in medicine advances at a rapid pace.  In the US today most patients have access to mobile phones, smartphones and tablets.  Medical device makers continue to innovate and create ways in which these technologies can be used by patients and physicians to monitor complex biologic machinery such as implantable cardiac defibrillators (ICDs) and Pacemakers at home–without the need for routine office visits.  These technologies create large masses of DATA.  These home-generated data can be instrumental in managing chronic disease  but can also create logistical as well as legal issues for physicians and their staff.

For the longest time, physicians have relied on patients to bring in a log of their blood pressures or blood sugars from home (often scribbled on a notepad, and often not accurately recorded) in order to determine when medication adjustments are needed.  In patients with congestive heart failure, physicians rely on a log of daily weights in order to make changes in the patients daily diuretic regimen in an effort to prevent hospital admissions for decompensation.  Now, device makers have created insulin pumps and glucometers that can be downloaded to a laptop and the information emailed to the physician for analysis.  ICD makers such as Biotronik actually have created cell phones that interact with the implanted device and transmits regular data to the physician 24 hours a day.

The big question is:  Does home monitoring really make a difference in outcomes and does it impact cost of care?

This week in the Annals of Internal Medicine, an important meta analysis was published evaluating the effectiveness of home monitoring technology on outcomes in patients with high blood pressure.  In the study, 52 different comparative trials were analysed.  Each of these trials evaluated the effectiveness of home monitoring of blood pressure and compared outcomes to patients who received home monitoring plus additional online or in-person support.  The study showed that all patients who had remote home monitoring of blood pressure had lower readings at 6 months but only those with home monitoring plus additional infrastructure and support from their physician’s office had more long term benefits.  Moreover, those patients with the added support experienced a more substantial reduction in blood pressure when compared to standard care or to remote monitoring without additional support.

As reported in the Wall Street Journal this week, the economic impact of home monitoring and data management on physicians and physician practices may be significantly negative.  Currently, physicians are not reimbursed for much of the home monitoring data management (with the exception of ICDs and Pacemakers which are reimbursed by medicare).  Many practices are hiring complete departments of highly skilled nurses and staff to deal with the enormous amount of incoming patient data from remote sources.  The additional staffing required to process and react to home monitoring data creates additional overhead–all in a practice setting where reimbursement continues to decline.  At some point, something has to give.

Don’t get me wrong, I am a huge proponent of the ePatient and of mHealth.  Using technology to help patients manage chronic  illnesses at home is the way medicine will be practiced in the future–and this practice will ultimately improve outcomes.  However, as technology advances, we must also find a way to advance the way in which physicians and their staff are able to process and utilize data in a cost effective and meaningful way for the patient.  If the government intends to successfully overhaul healthcare and institute a fully electronic universal electronic medical record, then some consideration must be given to practice workflow, data management and the costs associated with the challenges that these new frontiers will present.

The Annals of Internal Medicine study is clear–home monitoring and data collection helps patients manage their chronic disease–BUT, the largest benefit is seen when home monitoring is combined with additional support from the patient’s healthcare team.

Unknown

The Blogging Patient and Cyberspace: Unlimited Possibilities for Improving Health and Battling Disease

Social media has opened a whole new world for patients.  Now, information about disease is readily accessible and available to everyone.  Certainly, there are issues with reliability and accuracy of internet sources and this can create uneasiness and misunderstanding for both physician and patient.  However, the internet can also provide many new therapeutic possibilities.  In particular, online support groups, twitter chats and blogging can provide a positive outlet for patients suffering with disease.  Today, I want to focus on one of these internet opportunities–the patient blog.  Recently, a online article on iHealth Beat explored this concept  of patient blogging and its benefits.

Just as commonly experienced in the climax and resolution phase of Greek tragedy, writing a blog about one’s experience as a patient can be cathartic.  Patients with chronic illnesses or with a new diagnosis are often confused, frightened and angry.  Numerous studies in the psychiatry literature have demonstrated that journaling or writing about one’s feelings and experiences can have a very positive effect on emotional health.  Journaling has been shown to have several other unexpected benefits as well.  In the age of the internet and social media, journaling is now called blogging.  Blogging can be a private posting (where only you  or those you approve can see) or can be made public for anyone to see.

Blogging can have many benefits that are very similar to journaling.   From a pure neuro-biological standpoint, while you are occupied with writing, the analytical left brain is engaged in the writing process.  This allows the right brain to be free to feel, emote and create.  In this setting, you are able to better understand yourself and the world around you.  Specifically, there are four distinct benefits that patients can receive from blogging that I believe are worth mentioning:

1. Blogging helps to clarify thoughts and feelings:  Often writing down our feelings provides a way for us to better organize our thoughts.  Blogging can help patients with terminal illnesses better understand their disease and how they are reacting or adjusting to the challenges of the diagnosis and/or therapy.

2. Blogging helps you to get to know yourself better:  Writing routinely will help you better understand what makes you happy and content.  Conversely, writing will also help you better understand what people and situations upset you.  This can be incredibly important when battling chronic disease.  It is important that you are able to spend more time doing the things that make you happy and are able to identify and avoid things that are upsetting.

3. Blogging helps you to reduce stress:  Patients who receive a diagnosis of a major illness or who suffer daily with the challenges of chronic disease often have a great deal of anger and resentment.  It is human nature to ask questions such as “why me?”.  Blogging about angry feelings can be a positive and therapeutic release of emotion.  It allows for the writer to return from the blog more centered and better equipped to deal with negative emotion

4. Blogging helps unlock your creativity:  Often we approach problem solving from a purely left brain analytical perspective.  This is how we are taught throughout our education to attack problems in math and science in school.  However, some problems are only solved through creativity and through the use of a more right brain approach.  Writing allows the right brain to creatively attack problems while the analytical side of the brain is occupied with the mechanics of the writing process.

I believe that blogging can be just as important as medication compliance in patients with chronic disease.  The diagnosis of a chronic disease can produce a great deal of stress and emotional angst.  Patients who are able to deal with negative feelings and emotions in a more positive way are better suited to tackling their health problems.  As mentioned above, blogging has many benefits on our emotional health.  By dealing with negative emotions and unlocking creativity, we are better able to deal with the realities of chronic disease and more effectively interact with friends and loved ones.  I encourage everyone–patient, physician, family member or friend–to begin to blog.  I expect that the health benefits of writing will be well worth the time in front of the computer screen and the insights that you may discover about yourself may be be life changing.


shakespeareblog

 

Twitter Moves Markets: Can It Impact Disease?

For those who are engaged in social media, nothing is more powerful than an active Twitter account. Twitter demands engagement and fosters a sense of community. Medicine, although quick to adopt many new technologies has been slow to embrace social media outlets and, in particular, Twitter. The ability to share ideas and information in 140 characters provides a unique platform for physicians to communicate with one another, with patients and with the world. Twitter allows physicians to teach, to counsel, to support and to dispel rumors and myths. Twitter allows physicians from different parts of the world to consult with one another and share knowledge in order to determine the best treatment plan for a particular disease process or patient. Twitter affords patients with an opportunity to connect with other patients who may have similar medical problems and challenges.

Recently, as many who follow the financial markets are aware, the Dow Jones average took a 144 point plunge in 2 minutes.

P1-BL255_TWEET_NS_20130423190304

Fortunately, the market quickly rebounded and within a few minutes was back to its opening level. The SEC determined that a tweet suggesting violence or terrorism at the White House was responsible for the plummet. The tweet had been produced from a “hacked” Associated Press (AP) twitter account. As reported in the New York Times today, regulators have taken notice to the power of social media. The incident with the stock market serves to further demonstrate the influence that twitter and other social media outlets can have on human behavior as their repercussions on government and financial institutions. In the case of the Boston bombing tragedy on April 15th, social media and mobile technologies provided much needed evidence and assisted in police efforts to apprehend the men who carried out the senseless attack.

So, why are physicians and other healthcare providers so reluctant to embrace Twitter?

I think that there are several reasons and many valid concerns. Here are some of the most common: (The Top Three Questions I get when discussing social media with physicians)

1. “Silly Rabbit, Twitter is for kids”–Dispelling the Myth

Most often, when I ask colleagues, they respond by saying that twitter is something that their kids use on their iphones. They do not see it as a viable option for a serious medical professional. However, done correctly, Twitter has the potential to impact patients, physicians and healthcare as a whole.

Unknown

2.” I’m Late, I’m Late, I’m Late !” Twitter is time consuming–This is absolutely the truth

Providing engaging and meaningful twitter content takes time and research. Physicians must commit to the daily effort of developing new tweets that make people want to follow you and engage in conversation. Just as time management during residency and fellowship was critical to success, time must be set aside every single day and devoted to producing content and engaging with those in cyberspace.

Unknown-1

3. Twitter may not be something my Lawyer wants me to use–Legal implications of online engagement are real.

Before embarking on a social media campaign in medicine, it is essential that you meet with a legal professional and develop guidelines for your social media presence. Understanding exactly what constitutes a doctor-patient relationship and the nuances of HIPAA laws are important considerations. An excellent resource is www.lawandmedicine.com . Victor Cotton, a MD, JD provides wonderful insight into these issues and can be a great place to start. By having a good understanding of the legal issues surrounding online professional interactions and using a little common sense, many pitfalls can be avoided completely.

Unknown-2

So, What is the bottom line?

Twitter is a powerful tool. To date, only a very small percentage of healthcare professionals are engaged. Not surprisingly, the new generation of physicians that are training today are much more involved in twitter and other social media outlets. A recent survey found that 95% of all medical students use at least one form of social media as compared to 40% for practicing physicians. Twitter provides an enormous opportunity to impact disease, educate our patients and interact with and learn from colleagues. WE, as physicians, must act now–we must shape the way in which social media will be utilized in medicine in the future. The time is now–we can move markets AND impact disease

Unknown copy

Interpreting Physician Rating Websites: Garbage IN Equals Garbage OUT

In the past, learning about a good doctor or a pleasant hospital experience was a “word of mouth” phenomenon.  Today, more and more patients are going online for information about potential healthcare providers and hospital systems.  But exactly how accurate is the information they are accessing?  Recently, multiple surveys and research investigations have been published about the validity of online physician review sites.  Like most things that we find on the internet, the best advice is to take what you see there “with a grain of salt”.

A recent survey performed by the Pew Research Center asked participants a simple question.  “What percentage of adult internet users have consulted or posted online health reviews?”  The results are quite startling.  The minority of users actually post–but a fair number of users read and consult these reviews.

Source:  Pew Research Center “Health Online 2013”

So, as consumers of healthcare, how in the world do we interpret this data.  The fact that only 3% of the folks surveyed actually posted reviews suggests that the reviews are somehow biased–either good or bad.  This can certainly lead to misleading comments and ratings and can drastically change how a provider is perceived.  We must remember that these MD ratings sites are unregulated and not very well controlled or policed.  Typically, in any customer service industry, we find that most comments come from dissatisfied customers–it is rare in corporate America that someone takes the time to leave a positive comment.  There have been many published studies in the literature have shown that negative events are much more likely to elicit comments.

An article published in the New York Times in March 2012, discusses the neuropsychiatric basis for this very fact.  In the article, Stanford researcher Dr Clifford Nass states that the brain handles positive and negative events differently and in these events are even processed in separate locations within the cortex.  His research has demonstrated that we tend to process negative experiences more thoroughly and tend to ruminate about negative more than positive–in other words it takes many many positive experiences to overcome one negative interaction.  A recent study in the Journal of Urology evaluated the ratings of common sites such as Vitals.com, Healthgrades.com and RateMDs.com and found that from a random sample of 500 Urologists whose ratings were examined, the average number of evaluations for each was 2.4 ratings.  Many of the reviews focused more on the office experience (decor, wait times, etc) rather than the interaction with the physician or the providers knowledge or ability.  Obviously with very few respondents the results can be significantly skewed by either a remarkably high or a remarkably low rating.  The results suggest that physician rating sites are probably not the most effective way to evaluate your next  potential healthcare provider

What are some possible sources of bias in MD ratings?  The internet allows for anonymity and promotes the ability to say things that we normally may not say in a face to face interaction.  Disgruntled employees, angry family members or patients frustrated by their disease may provide unwarranted negative ratings to healthcare providers.  Conversely, family members and friends may also provide unwarranted high praise.  Altogether, these types of bias limit the utility of physician ratings sites.  Other options for choosing a provider include social media sites such as twitter.  There are disease specific tweet chats that promote interaction among patients.  Patients in the chat often recommend certain therapies, physicians and hospital systems.  These groups tend to be very well informed and the information is fairly reliable.  Ultimately, as an article on the NPR website last week suggests–we  may just have to go back to the prehistoric pre-digital era when it comes to rating and choosing physicians–we might just have to talk to one another!

dinosaur computer

Policing The Internet: Physician Behavior In Cyberspace

In the last few weeks there have been several articles published examining the behavior of physicians and other healthcare providers on social media outlets.  Certainly, professionals must take care as to what is posted online–as I tell my 11 year old daughter–the internet is forever.  Social media is now commonplace and smartphones and tablet computers make for almost unlimited access.  Because of the ease of use and ubiquitous access to social media, these outlets can be a powerful tool for interacting with patients.  As you might imagine because of visibility, the internet and social media outlets in particular, are another enormous area for potential regulation.  Physicians are held to high standards for behavior both in and outside of the hospital (as they should be) and the cyberspace is no exception.

In spite of the potential pitfalls of social media, I believe that reaching out to patients and colleagues via cyberspace is the future of medicine and will positively impact our ability to provide healthcare in the future.A recent study published in Archives of Internal Medicine in January identified high risk online physician behaviors to be avoided.  As the authors state, there are no formal policies in place  to address physician online behavior in most state medical boards.  However, the intent of the Archives article was to identify behaviors that are likely to be considered violations of online professionalism.  Many of the behaviors identified are just simply common sense–Physicians should not post pictures of drunken debauchery or make inappropriate, sexist or racist comments on social media outlets.  In addition, physicians should never inaccurately present outcomes data, present false credentials, or post pictures without patient permission.  Most certainly, physicians should not engage in non professional relationships with patients in cyberspace.  A recent article on the NPR website published examples of tweets that are likely to get a physician in trouble with professional governing bodies.

Yesterday in the Wall Street Journal, author Anna Mathews explores the controversy associated with physician-patient relationships on Facebook.    In the world of social media, Facebook is the number one viewed website in the world.  It facilitates connections between old friends and fosters new interactions.  However, when physicians become active on Facebook, there is potential for both positive and negative impact.  In a survey in the Journal of General Internal Medicine, researchers found that nearly 85% of all medical students are involved in social media sites–this suggests that the next generation of physicians will become increasingly more active and engaged with each other and with patients via sites like Twitter and Facebook in the future.  Another survey found that while more than 80% of physicians who are active on Twitter and Facebook are likely to engage and interact with one another, less than 8% interact with patients via social media.  However, for those that do use Facebook and Twitter to interact with patients, there are significant legal and ethical questions that arise.  In an extreme example discussed in the WSJ article, one physician actually returns calls when contacted via his Facebook account.  I worry that universal and unrestricted access to healthcare providers may blur the line between one’s personal and professional lives.  In order to provide the highest quality care, physicians and other healthcare providers must also have some downtime–everyone needs to recharge and relax.  Moreover, once a provider sets a precedent for interacting via social media with active patients (and establishes a doctor-patient relationship) a legal obligation to continue to respond in the same manner may be created.  Just how deep does the rabbit hole go?

I am an active social media user.  I enjoy engaging other physicians and patients in cyberspace.  I believe that social media is a powerful tool that medicine and physicians must embrace.  However, I am careful in how I interact with patients and colleagues in the social media world.

Here are my thoughts:

Things to AVOID in Medical Social Media

1. Never share privileged information
2. Never identify patients or provide information that could be used to identify patients
3. Never, ever give specific medical advice to a patient (never ever engage in patient care and create a doctor-patient relationship)
4. Never misrepresent my credentials or my training and expertise
5. Never provide inaccurate outcomes data
6. Never post pictures or make statements that reflect poorly on my professional reputation

Things to DO EVERY DAY in Medical Social Media

1. Engage your audience with interesting posts–provide commentary on timely medical information as it is released in the press
2. Promote yourself and your abilities–let potential patients and other providers know what you do and how to reach you
3. Become a Key Opinion Leader–engage colleagues in discussions about current therapies, emerging technologies, etc4. Educate–Twitter, Facebook and Blogging are great ways to teach patients about health related topics of interest WITHOUT developing a doctor-patient relationship and giving patient specific device.  Patients frequently turn to the internet for medical information.

Social Media is the final frontier for the doctor-patient relationship.  As physicians and healthcare providers we are held to high behavioral standards.  In addition, legal considerations abound in medicine today and will continue to be an issue until our country addresses tort reform.  As a profession, we must develop standards for online behavior based on good judgement and common sense.  In addition, we must learn to embrace the power of social media and maximize its potential positive impacts on our patients and our profession.

Unknown

Genomics at your fingertips: DNA Sequencing in the Primary Care Office

Personalized medicine is on the horizon. Social media, wireless devices, mobile smartphones and emerging medical technologies have allowed us to track our own health indicators and monitor our bodies like never before. Genomics allows us to better understand why certain people are more susceptible to certain diseases and why disease may be more aggressive in particular individuals. Combining the power of data with the power of genomics will revolutionize the way in which we care for patients in the future–most likely this will occur in my lifetime.

Imagine a day in which you are given a prescription that is specifically made to target disease in YOUR body based on YOUR own genetic characteristics. The future of medicine is in genomics. Diseases that have been long thought incurable or untreatable may very well be cured and successfully treated through matching DNA and therapies. In the past genetic sequencing has been a tool of the research center and has been cost prohibitive for most–nearly $250,000 dollars per genome. Now, technology has improved significantly and sequencing is around $6000 dollars and is expected to drop even further.

This week in the New York Times, author Anne Eisenberg describes a new company that is marketing genomic sequencing machinery (cleverly called Knome)–currently these are being sold to academic and private research laboratories at about $125,000 dollars each. However, in the not so distant future, I can imagine a world in which a primary care physician has a sequencer like the Knome on-site and is able to analyze your DNA when you come into the practice as a new patient. Your personal physician can then utilize the information for choosing your therapies for years to come. If you move or transfer care to another provider, your genome sequencing would transfer with you–just like your medical records do now. I would also expect that ultimately we would have an encrypted national database of our personal genomes so that when you are travelling and need medical care, a provider in an Emergency Department in another part of the country can (with your permission of course) access your genome data when prescribing therapy.

Certainly, genomics has much promise. We are just beginning to see the potential that targeted therapies can have on treating particular forms of certain cancers. As our knowledge of genomics increases and the availability of DNA sequencing becomes more mainstream the archaic data driven population approaches to treatment of disease are likely to be abandoned for more efficient, more effective and more directed, patient specific approaches. The transition to the genomic based practice of medicine will not be without difficulty. As we approach a time when patient-specific genetic information will be commonplace, we must prepare for the inevitable administrative responsibilities and controversy that are sure to arrive at the same time. Protecting individual privacy (and you think HIPAA is bad now) and avoiding discrimination for “genetic predisposition” to particular disease come to mind as potential hot button issues. However, the potential impact on our ability to practice medicine is infinite. As Dr Eric Topol clearly articulates in his book The Creative Destruction of Medicine, doctors will be able to combine data obtained from personal technology with powerful genome sequencing tools to provide the BEST medical care where drug effects are predicted and diseases are treated with certainty as opposed to a trial and error approach. Ultimately, the digital revolution will improve healthcare and allow for new technology and tools such as genome sequencing to be quickly incorporated into everyday practice.

So, one day in the not so distant future, I expect all of us will know our own genetic sequences. A visit to the doctor will likely include a look in your ears, a look in your throat, a stethoscope on your chest AND a quick glance at your DNA….

cheap-genome-sequence