A Physician Perspective On Mobile Healthcare by Brian Gould M.D.


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A unique and global physician's view of mobile healthcare by Brian Gould MD at the Mobiquitous Conference in Toronto, Canada, July 2009. DRAFT Slides from a Flash presentation. Contact Dr. Gould through Information Advantage Group.

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  • Smartphones allow users to create highly personalized environments configured for preferences location-awareness ability to manage all data formats – audio, data, photo, video (live and recorded) iPhones account for only a fraction of smartphones/PDAs worldwide (15.1 iPhone and iPod Touch devices in May 2009), but the overwhelming majority of smartphone Internet traffic “ Medical Tourism” as local center of excellence, technology diffusion point
  • Leadership in mobile health innovation does not automatically go to the industrial West. Third world projects are proliferating and scoring impressive successes “ mHealth” = mobile health technology  Ubiquity Multidirectional information flow Interactivity Personal convenience Phones are inexpensive, already in common use. Can be re-charged at night with generators if necessary. To make the user interface simple and friendly, the hardware/software infrastructure needs to be sophisticated (complex), but that is being developed. (Frontline SMS is a free application that allows health officials to analyze a large volume of text messages with the need for central servers or even Internet access.) Dr. Nathan Wolfe, head of the Global Viral Forecasting Intiative (GVFI): “If the Internet is humanity’s planetary nervous system, we are now building our planetary immune system.”
  • Hardware/software purchase model – common for IT – is wrong for small practices
  • #1 examples – “meaningful use” requires physician to have all relevant patient data at point of care, regardless of origin or network carrier. Conflicting standards example – decision of CMS to pay for Zostavax vaccine under Medicare Part D. No way for medical offices to get reimbursed (they are not pharmacies). #2 -- Quoting Max Planck, “in the correct formulation of the question lies the key to the answer”, Ball et al. ask, “Why has health IT failed to provide the systems and appliances that clinicians will use?” They answer themselves, (we are dealing with) “… a more fundamental ‘systems’ failure. The computer science domain lacks the methods and tools to represent the complexity of user tasks, the contexts and sets of information and knowledge that must be harvested for context-relevant information push and pull in health care.” platform independence diverse input/out capabilities ubiquitous access easy user customizability ability to work with existing and emerging systems open architecture – accepts commercial off-the-shelf components ability to manage multiple tasks, and multiple patients Workstation “inbox” (Ball et al.): information broker – interface the workstation system with existing information resources and network services task/context manager - to track and support multiple activities and multiple patients human computer integration manager – to present information to and gather information from the clinician in ways that are easily understandable and consistent with the physician’s preferences
  • Physician resistance not just a US phenomenon. Compared to European HCIT conversion, US docs have had more opportunity to reject the technology; in Europe, was not an option. Just happened despite some significant physician resistance. (What the Dean of Harvard Medical School describes as “a forced march” for the profession.) European physician objections noted [good summary of US physician objections as well]: failure to include physicians in the design process* failure to demonstrate value to the clinical process (e.g. clinical decision support) ensure the privacy of personal data “ Changing systems means changing behaviors” -- unintended consequences to patient care? Who looks at impact at point-of-care? (“e-iatrogenesis”) Workstation “inbox” (Ball et al.): information broker – interface the workstation system with existing information resources and network services task/context manager - to track and support multiple activities and multiple patients human computer integration manager – to present information to and gather information from the clinician in ways that are easily understandable and consistent with the physician’s preferences
  • Attention in US right now is on conversion to EMRs, but that shouldn’t be confused with the actual goal. The long-consequences of HC digitization will be far more penetrating. As was often said about other industries during the Internet bubble days a decade ago, “ … will change everything.” Pressure to open networks so  location-based services, universal access to data, interoperability
  • A Physician Perspective On Mobile Healthcare by Brian Gould M.D.

    1. 1. The Physician Perspective On Mobile Healthcare Humanitarian Technology Challenges and Interoperability Workshop Brian S. Gould, MD Information Advantage Group www.iagllc.com July, 2009
    2. 2. Current HCIT Trends – Synergistic <ul><li>Digital Conversion of Health Care Information </li></ul><ul><ul><li>Electronic records (US trails, but ARRA 2009 funding will accelerate adoption) </li></ul></ul><ul><ul><li>Electronic clinical processes (e.g. eRx) </li></ul></ul><ul><ul><li>“ Meaningful use” requirement will  integrated provider data-communications </li></ul></ul><ul><ul><li>Medical journals and CME on Internet and podcasts </li></ul></ul><ul><li>Consumer Connectivity </li></ul><ul><ul><li>Increasing use of Internet health information </li></ul></ul><ul><ul><li>Personal Health Records (WebMD, Google Health, MS HealthVault, Aetna) </li></ul></ul><ul><ul><li>Health-related Web 2.0 social networking </li></ul></ul><ul><li>Telemedicine </li></ul><ul><ul><li>Increasing demand </li></ul></ul><ul><ul><li>Increasing physician acceptance and innovation </li></ul></ul><ul><ul><li>Payment formats lagging, but catching up </li></ul></ul><ul><ul><li>Will boost Medical Tourism </li></ul></ul><ul><li>Mobility </li></ul><ul><ul><li>The “Smartphone phenomenon” </li></ul></ul><ul><ul><li>Wi-Fi/cellular connectivity  realization of “Ubiquitous Computing” </li></ul></ul>Information Advantage Group LLC
    3. 3. Third World mHealth Initiatives <ul><li>UN and Vodafone Foundations document four dozen mHealth projects now active in various developing nations </li></ul><ul><li>Many use push text messaging to maintain private contact with HIV-positive men (e.g. Project Masiluleke, RSA) </li></ul><ul><li>Others use mobile phones as EMR data entry points ( e.g. Rwanda public health officials routinely use mobile phones to transmit health data, order medicines, send public health alerts and download medical guidelines) </li></ul><ul><li>In other parts of Africa, “ Doc in a box ” clinics use mobile phone system to provide remote medical support to community health workers </li></ul><ul><li>Mobile devices can integrate with “ lab on a chip ” digital detection technology to improve distance diagnosis </li></ul><ul><li>Medicall Home (Mexico) – provides unlimited physician mobile phone consultations to 4.5m customers for $5/mo. </li></ul><ul><li>Adding “ rumor registries ” to social networking sites make them useful for predicting infectious disease outbreaks and other public health surveillance </li></ul>Information Advantage Group LLC
    4. 4. The Smartphone Phenomenon <ul><li>Physician adoption of smartphones accelerating </li></ul><ul><ul><li>2001: 30% (18% reported using for clinical purposes) </li></ul></ul><ul><ul><li>2007: 50% </li></ul></ul><ul><ul><li>1Q 2009: 64% </li></ul></ul><ul><li>Physicians now routinely using to access online medical and pharmaceutical resources </li></ul><ul><li>Representative from FDA Center for Devices & Radiological Health presenting at TEPR+ Conference, Feb. 2009: FDA may want to regulate iPhone Health Apps as “wireless medical devices” </li></ul>Information Advantage Group LLC
    5. 5. <ul><li>Predictions: </li></ul><ul><li>Adoption of EMRs will proceed more quickly among BlackBerry Docs (AMGA reports 85% EMR adoption by its large groups) </li></ul><ul><li>Use of mobile, smartphone-based clinical tools will initially be more popular among iPhone Docs </li></ul><ul><li>Different paths, but eventually both groups will achieve a new condition in the history of Medicine – Continuous Patient Care based on ubiquitous computing </li></ul>Information Advantage Group LLC “ BlackBerry Docs” “ iPhone Docs” Large groups, primarily contract-based Smaller practices, primarily FFS Departmentalized; professional IT support Haphazard IT support, often non-professional, often personal Formal financial management, ROI-focus Small business cash accounting Formal IT planning and specifications process “ iTunes distribution” of low-cost, personalized clinical applications Intolerant of advertising More tolerant of advertising, other forms of sponsorship More tolerant of cost, inconvenience of EMRs Extremely critical of EMR time-sink, operating costs, added liability exposure
    6. 6. Ubiquitous Computing  “Continuous Integrated Care” <ul><li>Smartphones are secure, portable but location-aware, single-user devices </li></ul><ul><li>Automatically connect to broad, wireless system of distributed devices </li></ul><ul><ul><li>Optical and RF tagging </li></ul></ul><ul><ul><li>Wearable sensors </li></ul></ul><ul><ul><li>Other smartphone peripherals </li></ul></ul><ul><ul><li>Medical Home </li></ul></ul><ul><li>Allows continuous, automated monitoring of data stream </li></ul><ul><ul><li>Treatment adherence </li></ul></ul><ul><ul><li>Detection of abnormal conditions </li></ul></ul><ul><li>Always-on communications </li></ul><ul><ul><li>Source for additional educational information (incl. multimedia) </li></ul></ul><ul><ul><li>Organizer for instructions, reminders, prompts, new data recording (incl. short-form video) </li></ul></ul><ul><ul><li>Push alerts and messages to providers, patients, families </li></ul></ul><ul><ul><li>Opportunities for environmental modification, active prevention </li></ul></ul><ul><ul><li>Initiate rapid responses </li></ul></ul><ul><li>Social networking  “care communities” </li></ul>Information Advantage Group LLC
    7. 7. Clinician’s Point-of-Care Workstation <ul><li>To achieve adequate Health Information Exchange must overcome high level of systems/data fragmentation, conflicting formatting standards, proprietary access barriers </li></ul><ul><li>Needs high level of user-flexibility, personalization -- data stream aligned with physician “thoughtflow” – how the individual clinician is thinking about the problem being solved; what info needed now? </li></ul><ul><li>Needs user interface that’s intelligent, customizable, adaptive. Should be personally “owned” by the clinician , so can be moved from location to location </li></ul>Information Advantage Group LLC
    8. 8. Physician Concerns <ul><li>Implementation </li></ul><ul><ul><li>Systems are costly and largely stand-alone, with limited data exchange </li></ul></ul><ul><ul><li>Impact on interdisciplinary staff training, clinical workflow, substantial </li></ul></ul><ul><li>Usability – do current IT systems meet provider information needs? </li></ul><ul><ul><li>Management of electronic records requires significant additional professional time – uncompensated </li></ul></ul><ul><ul><li>Not yet clear how to manage the “in-box” </li></ul></ul><ul><ul><li>Not yet clear how to handle email from patients </li></ul></ul><ul><ul><li>What are appropriate guidelines for patient-accessible medical records? </li></ul></ul><ul><li>Unknown consequences, but real fears </li></ul><ul><ul><li>HIPAA compliance – security protection is easy, maintaining patient privacy impossible </li></ul></ul><ul><ul><li>Increased malpractice exposure </li></ul></ul><ul><ul><li>e-data makes imposition of outside arbitrary “standards” easier, can lead to </li></ul></ul><ul><ul><ul><li>regimented care </li></ul></ul></ul><ul><ul><ul><li>even more defensive medicine </li></ul></ul></ul><ul><ul><ul><li>easy identification and prosecution of “outliers” </li></ul></ul></ul><ul><ul><ul><li>Cooling effect on clinical innovation </li></ul></ul></ul>Information Advantage Group LLC
    9. 9. Emerging Ecology of HCIT <ul><li>Physicians will adopt IT as long as it eases work and improves outcomes (e.g. smartphones) </li></ul><ul><li>The most popular new HC services pull through cellular network, add to pressure on wireless carriers to open </li></ul><ul><li>The traditional health care organization model is outmoded – “office visits” and “hospital admissions” will not fit the operating environment of continuous care or less location-dependent clinical care workflow </li></ul><ul><li>Geographically distributed, patient-specific treatment teams are now a practical reality </li></ul>Information Advantage Group LLC