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25 March 2012

Smartphone technology, super-convergence, and the great inflection of medicine

Filed under: books, Connected Health, converged medicine, healthcare, Internet of Things, medicine — David Wood @ 10:07 pm

You are positioned to reboot the future of medicine…”

That’s the rallying cry that rings out from Eric Topol’s marvellous recent book “The Creative Destruction of Medicine”.  The word “Destruction” is meant in the sense elaborated by Austrian-Hungarian economist Joseph Schumpeter.  To quote from Investopedia:

Creative destruction occurs when something new kills something older. A great example of this is personal computers. The industry, led by Microsoft and Intel, destroyed many mainframe computer companies, but in doing so, entrepreneurs created one of the most important inventions of the century.

Topol believes that a similar transformation is underway in medicine.  His book describes at some length what he calls a “super-convergence” of different technological transformations:

  • Genomics, which increasingly indicates connections between individuals’ DNA sequences and their physiological responses to specific drugs and environmental conditions
  • Numerous small sensors – wearable (within clothing) or embeddable (within the body) – that can continuously gather key physiological data, such as blood glucose level, heart rhythm, and blood pressure, and transmit that data wirelessly
  • Improvements to imaging and scanning, that provide clearer information as to what is happening throughout the body (including the brain)
  • Enormous computing power that can manipulate vast amounts of data and spot patterns in it
  • Near ubiquitous smartphones, which can aggregate data from sensors, host all kinds of applications related to health and wellness, and provide early warnings on the need for closer attention
  • 3D manufacturing and synthetic biology, that can create compounds of growing use in medical investigation and bodily repair
  • The adoption of electronic medical records, that allow healthcare professionals to be much more aware of medical history of their patients, reducing the number of problems arising from unexpected interactions between different treatments
  • The emergence of next generation social networks binding together patients with shared interest in particular diseases, allowing crowd-sourcing of new insight about medical conditions
  • Enhanced communications facilities, that enable medical professionals to provide advice and even conduct operations from far-distant locations
  • Improved, free medical training facilities, such as the short videos provided by the Khan Academy.

Topol has an impressive track record as a leading medical practitioner, and gives every sign that he knows what he is talking about.  Importantly, he maintains a critical, skeptical perspective.  He gives plenty of examples of where technology has gone wrong in medicine, as well as when it has done well.  His observation of the application of accelerating technology to medicine is far from a utopia.  There are two sorts of problematic factors: technology factors (including the complexity of the underlying science), and non-technology factors.

First, the technology factors.  The ways that individuals react to different medical treatment vary considerably: a drug that saves one life can have terrible side effects in other patients.  What’s more, diseases that were formerly conceived as single entities now appear to be multiple in nature.  However, the move from “population medicine” to “individual medicine”, enabled by advances in genomics and by powerful data analysis, offers a great deal of hope.  For one example of note, see the Wall Street Journal article, “Major Shift in War on Cancer: Drug Studies Focus on Genes of Individual Patients“.  The core principle is that of ever improving digital analysis of data describing individual people – something that Topol calls “digital high definition of humans” leading to “hyperpersonalisation of healthcare… fulfilling the dream of true prevention of diseases”.

But the non-technology factors are just as significant.  Instead of the complexity of the underlying science, this refers to the structure of the medical industry.  Topol has harsh words here, describing the medical establishment as “ultra-conservative”, “ossified”, and “sclerotic” – existing in a “cocoon” which has tended to isolate it from the advances in information technology that have transformed so many other industries.  Topol calls for “an end of the medical priesthood… the end of an era of ‘doctor knows best'”.  Associations of medical professionals who seek to block patients from seeing their own medical data (e.g. a detailed analysis of their personal DNA) are akin, Topol says, to the medieval priests who fought against the introduction of printing and who tried to prevent church congregations from reading the bible in their own hands.

Given such criticisms, it’s perhaps surprising to read the wide range of positive endorsements at the start of the book, from eminent leaders of the medical industry.  This includes:

  • The global president of R&D for Sanofi
  • The professor of genetics from Harvard Business School
  • The chairman and CEO of Medtronic
  • The professor and vice-chair of surgery from NY Presbyterian/Columbia University
  • The chief medical officer from Philips Healthcare
  • The executive vice president and chief of medical affairs from United Health Group
  • The president of the Salk Institute for Biological Studies

and many others.  And for a growing list of reviews of the book, including from many people deeply embedded in the medical industry, see this compendium on the 33 Charts blog.  What’s happening here is that Topol is drawing attention to structural issues inside the medical profession, which many other people recognise too.  This includes risk aversion, long training cycles that place little emphasis on information technology, funding models that emphasise treatment rather than prevention, tests that are unnecessary and dangerous, and lengthy regulatory processes.

If the problem is structural, within the medical industry, the fix is within the hands of patients.  As per the quote I started with,

You are positioned to reboot the future of medicine…”

Here’s the longer version of that quote:

With the personal montage of your DNA, your cell phone, your social network – aggregated with your lifelong health information and physiological and anatomic data – you are positioned to reboot the future of medicine.

Topol advocates patients take advantage of the tremendous computational power that is put into their hands by smartphones, running healthcare applications, connected to wireless sensors, and plumbed into increasingly knowledgeable social networks that have a focus on medical matters – sites such as PatientsLikeMe, CureTogether, and many others.

There’s an important precedent.  This is the way business professionals are taking their own favourite smartphones and/or tablet computers into their workplaces, and are demanding that they can access enterprise systems with these devices.  This trend – “bring your own device” (“BYOD”) – is itself a subset of something known as “the consumerisation of enterprise technology”.  People buy particular smartphones and tablets on account of their compelling ease of use, stunning graphics, accessible multimedia, and rich suite of value-add applications covering all sorts of functionality.  They enjoy using these devices – and expect to be able to be use them for work purposes too, instead of what they perceive as clunky and sluggish devices provided via official business channels.  IT departments in businesses all around the globe are having to scramble to respond.  Once upon a time, they would have laid down the law, “the only devices allowed to be used for business are ones we approve and we provide”.  But since the people bringing in their own personal devices are often among the most senior officials in the company, this response is no longer acceptable.

Just as people are bringing their favourite smartphones from their home life into their business life, they should increasingly be willing to bring them into the context of their medical treatment – especially when these devices can be coupled to data sensors, wellness applications, and healthcare social networks.  Just as we use our mobile devices to check our email, or the sports news, we’ll be using these devices to check our latest physiological data and health status.  This behaviour, in turn, will be driven by increasing awareness of what’s available.  And Topol is on a mission to increase that awareness.  Hence his frequent speaking engagements, including his keynote session at the December 2011 mHealth Summit in Washington DC, when I first became aware of him.  (You can find a video of this presentation here.)  And hence his authorship of this book, to boost public understanding of the impending inflection point in medicine.  The more we all understand what’s available and what’s possible, the more we’ll all get involved in this seismic patient-led transformation.

Footnote: Topol’s book is generally easy to read, but contains quite a lot of medical detail in places.  Another book which covers similar ground, in a way that may be more accessible to people whose background is in mobile technology rather than medicine, is “The Decision Tree: How to make better choices and take control of your health”, by executive editor of Wired magazine, Thomas Goetz.  Both Topol and Goetz write well, but Goetz has a particular fluency, and tells lots of fascinating stories.  To give you a flavour of the style, you can read chapter one free online.  Both books emphasise the importance of allowing patients access to their own healthcare data, the emergence of smart online networks that generate new insight about medical issues, and the tremendous potential for smartphone technology to transform healthcare.  I say “Amen” to all that.

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30 December 2011

Factors slowing the adoption of tablet computers in hospital

Filed under: Connected Health, mHealth, security, tablets, usability — David Wood @ 12:35 pm

Tablet computers seem particularly well suited to usage by staff inside hospitals.  They’re convenient and ergonomic.  They put huge amounts of relevant information right in the hands of clinicians, as they move around wards.  Their screens allow display of complex medical graphics, which can be manipulated in real time.  Their connectivity means that anything entered into the device can (in contrast to notes made on old-world paper pads) easily be backed up, stored, and subsequently searched.

Here’s one example, taken from an account by Robert McMillan in his fascinating Wired Enterprise article “Apple’s Secret Plan to Steal Your Doctor’s Heart“:

Elliot Fishman, a professor of radiology at Johns Hopkins… is one of a growing number of doctors who look at the iPad as an indispensable assistant to his medical practice. He studies 50 to 100 CT scans per day on his tablet. Recently, he checked up on 20 patients in his Baltimore hospital while he was traveling in Las Vegas. “What this iPad does is really extend my ability to be able to consult remotely anytime, anywhere,” he says. “Anytime I’m not at the hospital, I’m looking at the iPad.”

For some doctors at Johns Hopkins, the iPad can save an hour to an hour and a half per day — time that would otherwise be spent on collecting paper printouts of medical images, or heading to computer workstations to look them up online. Many doctors say that bringing an iPad to the bedside lets them administer a far more intimate and interactive level of care than they’d previously thought possible. Even doctors who are using an iPad for the first time often become attached, Fishman says. “Their biggest fear is what if we took it away.”

However, a thoughtful review by Jenny Gold, writing in Kaiser Health News, points out that there are many factors slowing down the adoption of tablets in hospital:

iPads have been available since April 2010, but less than one percent of hospitals have fully functional tablet systems, according to Jonathan Mack, director of clinical research and development at the West Wireless Health Institute, a San Diego-based nonprofit focused on lowering the cost of health care through new technology…

UC San Diego Health System’s experience with iPads illustrates both the promise and the challenge of using tablet technology at hospitals. Doctors there have been using the iPad since it first came out, but a year and a half later, only 50 to 70 –less than 10 percent of physicians– are using them…

Here’s a list of the factors Gold notes:

  1. The most popular systems for electronic medical records (EMRs) don’t yet make apps that allow doctors to use EMRs on a tablet the way they would on a desktop or laptop. To use a mobile device effectively requires a complete redesign of the way information is presented.  For example, the EMR system used at UC San Diego is restricted to a read-only app for the iPad, meaning it can’t be used for entering all new information.  (To get around the problem, doctors can log on through another program called Citrix. But because the product is built on a Windows platform and meant for a desktop, it can be clunky on an iPad and difficult to navigate.)
  2. Spotty wireless coverage at the hospital means doctors are logged off frequently as they move about the hospital, cutting off their connection to the EMR
  3. The iPad doesn’t fit in the pocket of a standard white lab coat. Clinicians can carry it around in a messenger bag, but it’s not convenient
  4. There are also worries about the relative newness of the technology, and whether adequate vetting has taken place over patient privacy or data security.  For example, as my former Symbian colleague Tony Naggs asks, what happens if tablets are lost or stolen?
  5. Some clinicians complain that tablet computers are difficult to type on, especially if they have “fat fingers”.

Let’s take another look at each of these factors.

1. Mobile access to EMRs

Yes, there are significant issues involved:

  • The vast number of different EMRs in use.  Black Book Rankings regularly provide a comparative evaluation of different EMRs, including a survey released on 3 November 2011 that covered 422 different systems
  • Slower computing performance on tablets, whose power inevitably lags behind desktops and laptops
  • Smaller display and lack of mouse means the UI needs to be rethought.

However, as part of an important convergence of skillsets, expert mobile software developers are learning more and more about the requirements of medical systems.  So it’s only a matter of time before mobile access to EMRs improves – including write access as well as read access.

Note this will typically require changes on both the handset and the EMR backend, to support the full needs of mobile access.

2. Intermittent wireless coverage

In parallel with improvements on software, network improvements are advancing.  Next generation WiFi networks are able to sustain connections more reliably, even in the complex topography of hospitals.

Note that the costs of a possible WiFi network upgrade need to be born in mind when hospitals are considering rolling out tablet computer solutions.

3. Sizes of devices

Tablets with different screen sizes are bound to become more widely deployed.  Sticking with a small number of screen sizes (for example, just two, as in the case with iOS) has definite advantages from a programmers point of view, since fewer different screen configurations need to be tested.  But the increasing imperative to supply devices that are intermediate in size between smartphone and iPad means that at least some developers will become smarter in supporting a wider range of screen sizes.

4. Device security

Enterprise software already has a range of solutions available to manage a suite of mobile devices.  This includes mechanisms such as remote lockdown and remote wipe, in case any device becomes lost or stolen.

With sufficient forethought, these systems can even be applied in cases when visiting physicians want to bring their own, personal handheld computer with them to work in a particular hospital.  Access to the EMR of that hospital would be gated by the device first agreeing to install some device management software which monitors the device for subsequent inappropriate usage.

5. New user interaction modes

Out of all the disincentives to wider usage of tablet computers in hospitals, the usability issue may be the most significant.

Usability paradigms that make sense for devices with dedicated keyboards probably aren’t the most optimal when part of the screen has to double as a makeshift keyboard.  This can cause the kind of frustration voiced by Dr. Joshua Lee, chief medical information officer at UC San Diego (as reported by Karen Gold):

Dr Lee occasionally carries his iPad in the hospital but says it usually isn’t worth it.  The iPad is difficult to type on, he complains, and his “fat fingers” struggle to navigate the screen. He finds the desktop or laptop computers in the hospital far more convenient. “Are you ever more than four feet away from a computer in the hospital? Nope,” he says. “So how is the tablet useful?”

But that four feet gap (and it’s probably frequently larger than that) can make all the difference to the spontaneity of an interaction.  In any case, there are many drawbacks to using a standard PC interface in a busy clinical setting.  Robert McMillan explains:

Canada’s Ottawa Hospital uses close to 3,000 iPads, and they’re popping up everywhere — in the lab coats of attending physicians, residents, and pharmacists. For hospital CIO Dale Potter, the iPad gave him a way out of a doomed “computer physician order entry” project that was being rolled out hospital-wide when he started working there in 2009.

It sounds complicated, but computerized physician order entry really means something simple: replacing the clipboards at the foot of patient’s beds with a computer, so that doctors can order tests, prescribe drugs, and check medical records using a computer rather than pen and paper. In theory, it’s a great idea, but in practice, many of these projects have failed, in part because of the clunky and impersonal PC interfaces: Who really wants to sit down and start clicking and clacking on a PC, moving a mouse while visiting a patient?

Wise use of usability experience design skills is likely to result in some very different interaction styles, in such settings, in the not-too-distant future.

Aside: if even orang utans find ways to enjoy interacting with iPads, there are surely ways to design UIs that suit busy, clumsy-fingered medical staff.

6. Process transformation

That leads to one further thought.  The biggest gains from tablet computers in hospitals probably won’t come from merely enabling clinicians to follow the same processes as before, only faster and more reliably (important though these improvements are).  More likely, the handy availability of tablets will enable clinicians to devise brand new processes – processes that were previously unthinkable.

As with all process change, there will be cultural mindset issues to address, in addition to ensuring the technology is fit for purpose.  No doubt there will be some initial resistance to new ways of doing things.  But in time, with the benefit of positive change management, good new habits will catch on.

29 December 2011

From hospital care to home care – the promise of Connected Health

Filed under: challenge, Connected Health, converged medicine, healthcare, mHealth, usability — David Wood @ 12:01 pm
  • At least one in four hospital patients would be better off being treated by NHS staff at home

That claim is reported on today’s BBC news website.  The article addresses an issue that is important from several viewpoints: social, financial, and personal:

NHS Confederation: Hospital-based care ‘must change’

The NHS in England must end the “hospital-or-bust” attitude to medical care, says the body representing health service trusts.

At least one in four patients would be better off being treated by NHS staff at home, figures suggest.

2012 will be a key year for the NHS as it tries to make £20bn in efficiency savings by 2015, according to the head of the NHS Confederation, Mike Farrar.

Ministers say modernising the NHS will safeguard its future.

Mr Farrar said: “Hospitals play a vital role but we do rely on them for some services which could be provided elsewhere.

“We should be concentrating on reducing hospital stays where this is right for patients, shifting resources into community services, raising standards of general practice, and promoting early intervention and self-care.

“There is a value-for-money argument for doing this, but it is not just about money and the public need to be told that – this is about building an NHS for the future.”

Mr Farrar said the required changes included treating frail people in their homes, and minimising hospital stays wherever possible.

Politicians and NHS leaders must show the public how these changes could improve care, rather than focusing on fears over the closure of hospital services, he added.

“Many of our hospitals know that the patients that they are treating in their beds on any given day could be treated better – with better outcomes for them and their families – if they were treated outside of hospitals in community or primary care,” he told BBC Radio 4’s Today programme.

Mr Farrar told Today that people had become used to “the hospital being a place of default” and that primary and community healthcare services had sometimes been under-funded.

But he said even where clinicians knew that better care could be provided outside of hospitals, and politicians accepted this privately, the public debate had not helped individuals understand that…

Some of the replies posted online are sceptical:

As a medical doctor based in hospitals, I believe this will not work logistically. Patients are sent to hospitals as they don’t get the specialist care in the community as the skills/services are inadequate/not in place. Patient attitudes must change as many come to a+e against GP advice as they don’t have confidence in community care…

As long as the selfish British public can’t be bothered looking after their own relatives and see hospitals as convenient granny-dumping centres, there is absolutely no way this would work.

There can not be a perfect solution. Not every family can care for a sick person full time, often due to them working. Hospital care may not be a perfect, yet in some cases it does free relatives to be able to work.  Outsourcing care too has a major downside, my wife has done that for years. 15 mins twice a day, can hardly be called acceptable if you apply some form of dignity to the patient.

I saw too many patients I nursed(often elderly or with pre-existing health conditions) kept in hospital too long because no one to care for them at home/wider community. This wasn’t great for them but also blocked an acute bed for someone else. In recent years the pendulum’s swung too far the other way: too many patients discharged without adequate support…

In summary: care in the community would be better in many, many cases, but it’s demanding and challenging:

  • There are social challenges: relatives struggle to put their own lives and careers on hold, to act as caregivers.
  • There are financial challenges: funding for medicine is often preferentially directed to large, centralised hospitals.
  • There are skills challenges: observation of complicated chronic health conditions is more easily carried out in the proximity of specialists.

However, the movement “from hospital care to home care” continues to gather steam – for good reason.  This was a major theme of the mHealth Summit I attended earlier this month in Washington DC.  I was particularly struck by a vision articulated by Rick Cnossen, director of worldwide health information technology at Intel:

In the next 10 years 50% of health care could be provided through the “brickless clinic,” be it the home, community, workplace or even car

As reported in the summary article by Kate Ackerman, “mHealth: Closing the Gap Between Promise and Adoption“:

Cnossen said the technology — such as mobile tools, telehealth, personal health records and social networking — already exists to make this possible. He said, “We have the technology. … It’s time to move out on it.”

Fellow speaker Hamadoun Toure, secretary general of the International Telecommunication Union took up the same theme:

Mobile phones will increase personal access to health information, mHealth and broadband technology will improve data collection and disease surveillance, patient monitoring will improve and become more prevalent, and remote consulting and diagnosis will be enhanced, thanks to low-cost devices.

“In the near future, more people will access the Internet through mobile devices than through fixed devices,” Toure said. “We are witnessing the fastest change in human history, and I believe (we have) a great opportunity for social development.”

Connected health technology enables better remote monitoring of personal medical data, earlier warnings of potential relapses, remote diagnostics, quicker access to technical information, better compliance with prescription regimes, and much, much more.

But Kate Ackerman raises the question,

So if the technology already exists and leaders from both the public and private sectors see the need, why has progress in mobile health been slow?

It’s an important question.  Intel’s Rick Cnossen gives his answer, as follows:

“The challenge is not a technology problem, it’s a business and a workflow problem.”

Cnossen said, “At the end of the day, mHealth is not about smartphones, gadgets or even apps. It’s about holistically driving transformation,” adding, “mHealth is about distributing care beyond clinics and hospitals and enabling new information-rich relationships between patients, clinicians and caregivers to drive better decisions and behaviors…”

He said health care clinicians can be resistant to change, adding, “We need to introduce technology into the way to do their business, not the other way around.”

Cnossen also said that payment reform is essential for “mHealth to survive and thrive.” He said, “We should not be fighting for reimbursement codes for each health device and app. That is ultimately a losing proposition. Instead, we must fight for payment reform to pay for value over volume, regardless of whether the care was provided in a bricks and mortar facility or was it at the home or virtually through electronic means.”

Personally, I would put the emphasis differently:

The challenge is not just a technology problem, it’s also a business and a workflow problem

Moreover, as the technology keeps on improving, it can often diminish the arguments that are raised against its adoption.  Improvements in quality, reliability, miniaturisation, and performance all make a difference.  Improvements in usability may make the biggest difference of all, as people find the experience in using the new technology to be increasingly reassuring.

I’ll finish by noting an excerpt from the keynote at the same conference by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services:

This is an incredible time to be having this conversation. When we talk about mobile health, we are talking about taking the biggest technology breakthrough of our time and using it to take on one of the greatest … challenges of our time. And while we have a way to go, we can already imagine a remarkable future in which control over your health is always within hand’s reach…

This future is not here yet, but it is within sight. And I look forward to working with you to achieve it.

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