Stay connected: mobile medicine11 November 2013
As each generation becomes more technology dependent than the last, young doctors and new patients are increasingly more receptive to mobile technology in medicine. Nic Paton speaks to Dr Joseph Kvedar, director of the Center for Connected Health at Partners HealthCare, Boston, about telemedicine and connected health.
Over the past decade, mobile technology has changed lives immeasurably, to the extent that, for many, it's hard to remember how people got by without smartphones or tablets.
This technology is also changing how physicians and patients interconnect, and could, in time, have the potential to transform not only the aesthetics of the healthcare system, but the physical presence and facilities.
One state in the US, Massachusetts, is pioneering the use of telemedicine and telecare. Here, a number of hospitals are incorporating remote patient-monitoring devices, smartphones, smart wristbands and other health-tracking devices into patient care, allowing patients to send data directly to their electronic medical record.
Such systems, which have been recognised for some time, can offer physicians the potential to make more informed clinical decisions and free them (and patients), in many cases, from the need for face-to-face appointments.
This technology can also allow physicians to track patients between office appointments and reduce visits to the accident and emergency department. As a result, this can potentially save hospitals and insurers money, as well as creating a more convenient, personalised, "always on" healthcare environment for patients and physicians alike.
However, as the technology becomes more prevalent and is considered mainstream within the healthcare system, it could start to pose difficult questions. One of which is the role of expensive "bricks and mortar" facilities, and the revenue flow of patients coming into the clinic or hospital for routine checkups and appointments that have been at the heart of investment in healthcare over the past few decades.
As Dr Joseph Kvedar, founder and director of the Center for Connected Health at the Boston-based Partners HealthCare argues: "If you look back 100 years, the hospital was the information centre; that was why people went to hospital, so they could be in one place where different physicians could assess and diagnose them and help them get better.
"Hospitals will, over time, devolve to sites specifically for intensive care and procedures. If hospitals are sharp, they will begin to shift resources towards prevention and wellness spaces with this sort of technology, and away from the traditional, expensive 'bricks and mortar'," he adds.
Time to upgrade
Other potential barriers include the issue of integrating technology within existing systems, educating patients so that they don't become obsessed with their health and therefore present at the slightest change in the data and, of course, the upfront investment required by healthcare providers to make the switch in the first place.
Nevertheless, Kvedar is confident that this is the way developments are going.
"Things will change, and are changing. I was, for example, speaking to a group of medical students one evening and they were puzzled as to why we had not got further along with this model of care. They are much more confident about using technology to stay in touch with patients, and so this is going to be the way it goes," he says.
The centre's Connected Health programmes primarily focus on chronic disease management, such as diabetes, hypertension and heart failure, as well as activity programmes in prenatal care, mental health, dermatology and addiction. A host of prevention and wellness initiatives are already changing how healthcare, monitoring and diagnosis are being delivered, he argues, and in ways that are proving popular with patients and physicians.
Patients can use glucometers, blood pressure cuffs, pulse oximeters (which measure blood oxygen levels) or even something as simple as a bathroom scale to take regular measurements and send them to their doctors.
"In my experience, patients are pleased with this mode of care delivery. It takes the hassle out of having to drive to the clinic, finding somewhere to park, waiting for their time in the examination room and so on; that all just goes away. There is also the reassurance that you have care whenever you need it," explains Kvedar.
"We've found patients adapt to using the technology quickly, from all age groups and from all walks of life. From a clinician standpoint, the notion of being able to bring up a dashboard view of the patient population is well liked; being able to see your population in this way and gauge wider health trends can be really valuable.
"Clinicians can make real-time, well-informed decisions, at a population level as well as an individual level," he adds.
A dermatologist by training, it was the increasing use of digital images as a substitute for a dermatological examination that sparked Kvedar's interest in this area, and the sense that there was an opportunity for clinicians to improve and change patient care.
"Our mission is to take the 'care' out of the traditional setting, out of the hospital or clinic and make it a continuous function in a patient's life. They do not have to visit the doctor for every single little thing; and if that can be achieved, we as physicians and nurses can do a better job of caring for patients who do," he says.
"A lot of the time, we are talking about chronic illness or prevention management, about the cluster of conditions that are often accompanied by lifestyle issues such as obesity, hypertension and diabetes.
"It is about collecting objective information regarding a patient: weight, blood pressure, heart rate, blood sugar for diabetes, and so on. And then helping them keep their healthcare at the front of their mind and change those parameters for the better.
"This technology is changing how to motivate people to stay in touch with their doctor. The healthcare provider or nurse also has a dashboard view of all the patients on the programme. So, if someone needs help they can get in touch with them. We have seen really positive clinical outcomes: decreased hospital admissions, lower blood pressure and so on," he adds.
For example, a 2012 study of Massachusetts adults with hypertension found a significant decrease in diastolic blood pressure among participants who took their readings and uploaded them to a web interface where they could track and monitor their progress.
Conversely, those who took blood pressure readings, but did not use the web programme, saw little improvement in their blood pressure and were less likely to seek medication or ask their doctor about making healthier choices.
Of course, one of the criticisms often levied at delivering care in this way is the danger that, as well as over-presenting, it can lull people into a false sense of security and, therefore, deter them from physically going to see their doctor when they should.
Kvedar concedes that this is an issue that needs to be actively managed. But he argues that, if anything, the opposite is more the case - that, by managing the day-to-day, low level consultations remotely, it gives the physician more time and ability to focus their efforts on those in most need, those who do physically need to be in front of a clinician in a consultation room.
"These types of systems do not promote the idea that you should never visit your doctors. Quite the opposite. What they emphasise is that this sort of model works extremely well for the low-emotional-value interactions, the things that you do not necessarily need to see a doctor for but for which, up to now, you've had little alternative but to do so," he emphasises.
"What it also means is that the doctor's time can be saved for helping patients who do need to see them. If you have, say, 12 conditions and are on 20 medications, then you will probably need to come in and see your doctor on a regular basis. But why should you also need to come in for a routine blood pressure check?" Kvedar adds.
"You cannot keep relying on physical one-to-one meetings to get things done. The trend is going to be more towards using communications and technology, particularly smartphones, to get everything done efficiently," Kvedar concludes.