Smart and smarter. The battle for the "smartest" watch

Following on from a blog post I wrote at the beginning of January the media attention around smart watches seems to have reached fever pitch. Thanks to @Paul_Sonnier's Digital Health Group on LinkedIn I came across this article about how Samsung are already launching their second generation smart watch. From what I can gather it does pretty much what the original Samsung Gear did, but has been redesigned to be more ergonomically sound.

As the article appears on a site called 9 to 5 Mac it's hardly surprising that the majority of the discussion is around when Apple are going to launch their smart watch. This article from a few days ago is quite fascinating, suggesting that Apple's new smart watch (note no-one is saying that Apple won't go down this route) is going to have way more health data functionality that just movement sensing.

As mentioned previously, although valuable, there has to be more to wearable devices that purely movement tracking to make them truly useful health management adjuncts for the masses. Jawbone, Nike and Fitbit have all done great jobs of taking the humble pedometer and transforming it into a piece of tech that can be integrated seamlessly into daily life (albeit with a slight bump in the road for the Fitbit Force), but this surely is just a first step.

For most of us our wristwatch is the only item we wear every day. It therefore makes sense to use it as the conduit to capture health related data. It doesn't seem beyond the realms of possibility to have a wristwatch continuously monitor heart rate, body temperature and movement throughout the day. Add to this an inference on how much sleep one is getting at night time (I say "inference" as all of the sleep monitoring apps and devices rely on interpreting movement, or lack of movement, at night time to crudely quantify sleep duration and quality) and you have a data stream that would be extremely useful in monitoring individuals with a number of chronic diseases.

Take for example someone with COPD (chronic obstructive pulmonary disease), a condition affecting 6.8% of US adults. Individuals with COPD are prone to "exacerbations" where a simple viral respiratory infection can lead to severe shortness of breath, copious mucus production and sometimes a super-imposed bacterial infection. If left unchecked an exacerbation can be life threatening and invariably requires hospital admission, however, if caught early and treated with antibiotics and steroids hospitalization can often be avoided. Now imagine someone with COPD wearing a smartwatch continuously transmitting data back to their provider. Their heart rate will increase a day or two before they start to feel unwell, their temperature may also increase. In addition, as the infection starts to take hold they'll probably feel more breathless and so won't be moving around as much as they normally do. The combination of these three data streams should be enough to identify an exacerbation at an early stage. With this early identification comes the ability to treat and the real possibility of avoiding a hospital admission. Now that to anyone's mind has to be a victory for health tech!

Prevalence of COPD in the United States. Image from CDC website: http://www.cdc.gov/features/copdadults/copdadults_a600px.jpg

 

    

It's Time to Practise Better Medicine

This article from @KathyKrostof on CBS got me thinking this week. Although as physicians we're no strangers to the art of complaining, it does appear that things are really getting strained out there on the front line. Talking to friends and colleagues from many different disciplines much of the frustration seems to stem from not being able to practise the sort of medicine we want to, and indeed signed up for when we first entered medical school. Too little time with our patients, over burdensome paperwork, a disjointed system where half the time we are in the dark as to what's happening with our patients outside of the office. I know I have to frequently spend significant amounts of time trying to piece together what's been happening with patients who see other specialists in different institutions; usually by wading through a disorderly pile of faxes or letters. This isn't medicine as it should be, this is fire fighting and disaster aversion. I am constantly amazed at how backward we have been, and to some extent continue to be, in how we practice medicine and deliver care.

This blog posting by @GertiTechBlog speaks volumes about the challenges faced by many of us, especially those working in primary care. And it is my feeling that the reason many physicians are feeling unhappy at the moment is not because they've fallen out of love with the practise of medicine, rather it is increasingly frustrating trying to do a good job.

Technology has transformed many aspects of our lives. It is sometimes hard to remember that we used to have to go to a travel agency to book a flight or a vacation, or go to a book store to buy something to read. Many of us now have complete control of our finances and bank accounts via the Internet and hardly ever have to visit a branch. Yet the practice of medicine has hardly changed during the time that this revolution has occurred in other areas of our lives. Why is this?

Part of the problem is undoubtedly the fact that as providers of care we have been extremely reticent to adopt new ways of doing things, preferring the status quo of the way its always been done. It wasn't a desire to practise better medicine that drove the uptake of electronic health records, it was the huge amounts of Federal incentives that made it happen. It really is very curious that it should take what is ostensibly a "bribe" from the government to do something positive, rather than taking it upon ourselves to enhance how we practise. Of course there is the debate that EHRs have not actually made the practise of medicine more efficient, cost effective or better...but that's a topic for another discussion!

Perhaps if we spent a little time looking at how other industries have developed and utilized technology over the past decade we could get some ideas on how we could improve what we do. I really do believe that the intelligent use of technology in our day-to-day interactions with patients and colleagues has the potential to improve how we feel about our jobs and also enhance our patients' satisfaction with the care we provide.

It's no secret that most major vendors of products and services have highly sophisticated customer retention and loyalty programs. They want to stay close to their customers, recommend other services that may interest them and find out what they think about what they've received to date. Now this is not a direct analogy with delivering medical care, but there are probably some aspects that still hold true. How difficult would it be for us to inquire from our patients how they are doing, what they thought of their last healthcare interaction and whether they were on track to reach the goals agreed on their last visit? Using traditional face-to-face interaction would probably prove quite difficult (or at least time consuming) for this, however, this is where technology can help and it is where the likes of Amazon, Expedia and Hilton, to name but a few, have excelled in driving loyalty and trust.

We need to think differently about how we deliver healthcare in the second decade of the twenty-first century. Storing information in an EHR is just the beginning, there are so many other ways we can interact and influence our patients in a positive fashion. Those of us who grasp this challenge, I believe, will drive better outcomes and greater value; two facets that are going to be integral to the future of healthcare.

nGage Health's patient timeline where all interactions with the healthcare system are graphically displayed for ease of review by both patient and provider.

Health Engine Optimization

I recently read this Wired article on search engine optimization (SEO) and how Google are potentially leveling the playing field by placing more emphasis on the value of the the content on a website. Rather than clever coding and tagging tricks that have traditionally been used to enhance a website's position in a search they are saying that it is the quality and relevance of the content that is going to dictate its position. You can't really say fairer than that you have to admit.

In a way an analogy can be drawn with healthcare and the need to optimize a process that for decades has functioned in a very nontransparent way. You become unwell, visit a doctor, get treated and (hopefully) get better. The process then repeats itself the next time illness strikes. This episodic approach is possibly fine (but not optimal) for relatively minor ailments, but as we age and the likelihood of developing chronic diseases increases, this approach often falls short of delivering quality care. By comparison with other developed countries the United States routinely languishes near the bottom for mortality from most chronic diseases. 

Healthcare reform may go some way to redressing this aberration (how the richest country with the most expensive healthcare system can consistently perform so poorly compared with other industrialized nations), but providers of care also have to critically examine how they deliver care. This I believe is where significant optimization can occur.

There is the dawning of recognition in the medical community that every episode of care does not necessarily need to be conducted in a face-to-face setting, or indeed happen in real time. But counteracting any significant change in how medicine is practiced are the perverse incentives associated with a fee for service model for remunerating providers. This is gradually changing, with greater numbers of physicians being employed by larger systems, opting to practice concierge style medicine, or participating in accountable care organizations. This will eventually mean the fee for service model won't be as big an influencer on behavior as it is today. 

As this change gathers momentum there will be an increasing need to modernize the way medicine is practiced, because provider remuneration will be based on outcomes and patient satisfaction, and not just episodes of care. This I believe is where technology comes in. As I mentioned, not all interactions need to be carried out face-to-face, and in fact some may even be better for not being face-to-face. This is not just telemedicine (although I am sure that it has a significant role to play in the future of healthcare) it's about utilizing technology to create an ongoing connection between provider and patient.

Imagine if providers had a dashboard that would give them access to regular, current data on, for example, diabetic patients' blood sugars, or an asthmatic patients' peak flow readings? They would be able to be proactive in managing these conditions both at the individual level, but also at the population level. The step change from the episodic reactive way of managing patients to one where there is a real opportunity to be proactive and predictive would surely improve outcomes, reduce costs and lead to greater patient satisfaction.  

This is not just a fantasy. It is happening in the here and now. At nGage Health we're creating solutions that allow providers to capture data from their patients (using health assessments and popular apps and devices) and merge that data with salient information from the EHR to generate a real-time population-wide dashboard, and we'd love to tell you more.   

nGage Health's Provider Dashboard for Population Health Management

ROI for Patient Engagement

The recent publication by the CDC on the prevalence of COPD (chronic obstructive pulmonary disease) is fascinating. Not just because it maps out the burden of this largely preventable disease within our country, but because it highlights to opportunities for population health management and patient engagement.

On average the prevalence of COPD in adults across the United States is 6.6%. In other worlds, one in every fifteen individuals had this disease. Now this is not quite as big an issue as diabetes within our society, but it is not far off, and the impact it has on healthcare delivery and costs is huge.

Not surprisingly the prevalence of COPD increases with age. This is because of the natural history of lung function decline. Once an individual is operating at about a third of their predicted lung capacity they become frequent users of healthcare resources, especially expensive emergency treatment

Take a population of five thousand individuals, the minimum number of patients an accountable care organization can be responsible for. Using the national average figures it is likely that 330 will have COPD to some degree of severity. In addition, according to the research 17.7% (or in this case 58) of these individuals will require hospitalization or review in the ER a year. Data from the American Lung Association suggests that the cost of such an admission is in the region of $20,000 per visit.

Undoubtedly some of these emergency admissions are totally warranted on clinical grounds, but as a pulmonologist I know that some are completely avoidable. There are two facets to this “avoidability”; the first is the fact that many (the exact numbers are rather hazy) patients do not take their prescribed medications as intended by their physicians. This non-adherence is often borne out of ignorance, rather than a conscious decision by individuals to be difficult or recalcitrant! Better education and the co-creation between doctor and patient of a self-management plans can have a dramatic effect here. The second issue is that we physicians often catch deteriorating patients late. Their exacerbation is in full swing and there is very little option but to transfer them to an emergency care establishment.

The solution to this last issue is a little more difficult. Many of my colleagues would day that there is nothing we can do. If a patient shows up with a severe exacerbation of their airways disease (or any other chronic condition for that matter), “how were we to know?”. This is true, however, it shouldn’t be the case. We now have the technology to keep in touch with our patients on a regular basis. I’m not even talking about sophisticated telemonitoring equipment here either. Secure email, text messaging, online symptom tracking should all be elements of a 21^st century physicians kit bag.

Just look at the savings that could be achieved by being more proactive. If just one exacerbation of COPD requiring hospitalization were prevented a year through this more proactive patient engagement approach that would be something, but I suspect that even in a 5,000 patient practice this number would be ten or twelve. And that’s just COPD…what about diabetes and congestive cardiac failure?