mHealth Technologies to Improve Outcomes Steve Steinhubl, MD Scripps Translational Science Institute 22 July 2014

1. mHealth Technologies
to Improve Outcomes
Steve Steinhubl, MD
July 22, 2014

2. Disclosures
• Scripps Translational Science Institute has
received grant support for research,
including salary support, from the
Qualcomm Foundation.

3. How many of you are set up to collect
these data from your patients?
1. Activity
2. Pulse
3. +/- Sleep

4. How about this information?
1. Activity
2. Pulse
3. Sleep stages
4. Blood pressure
5. Cardiac Output / Stroke Vol.
6. ECG
7. Stress
 HRV
 EDA
8. Respiration rate
9. Temperature
10. Oxygen saturation
11. CO2 levels
12. Glucose (?)

5. mHealth Technologies to Improve
Outcomes
1.What is mhealth , how did we get here, and
why should we care?
2.Examples of how mhealth can transform
healthcare.
3.Where is the evidence?
4.What will it mean for providers?

6. mHealth Technologies to Improve
Outcomes
1.What is mhealth , how did we get here, and
why should we care?
2.Examples of how mhealth can transform
healthcare.
3.Where is the evidence?
4.What will it mean for providers?

7. “mHealth (or mobile health) is the use
of mobile or wireless devices to
improve health outcomes, healthcare
services and health research.”
-NIH Consensus group
What is mHealth?

8. ASCI Red
• World’s fastest super-computer
in 1996 – 1.8 teraflops/sec
(1.8 trillion operations /sec)
• $55 million to develop.
• Occupied 1,600 square feet of
floor space.
• Used 800 KW/hr (~800 homes)
• 2006 – 1.8
teraflops/ sec
• $500
• 200 watts
• 64 million units sold

9. May, 1997
IBM’s Deep Blue
beat World
Chess Champion
Garry Kasparov.
Deep
Blue

10. http://www.nydailynews.com/news/world/c
heck-contrasting-pics-st-peter-square-article-
1.1288700#ixzz2ePFO9300
PC
Smartphones
Tablets
In the US, 91% of adults own
a mobile phone, with the
majority of them (61%)
being smartphones.
194 minutes a day looking
at smartphone or tablet
screen.
147 looking at TV, 103 at
laptop or PC.

13. A Historical (and Present Day) Look at Our Tools for
a Patient’s Office Visit
Blood Pressure
ECG
Physical Exam/Auscultation
House Calls
• Sphygmomanometer
invented 1881.
• Popularized by Harvey
Cushing 1901
1904
• Willem Einthoven 1901.
• Precordial leads
introduced 1944
1911
• Laënnec 1816.
• Binaural stethoscope
1851
1852
~1900
• In 1930’s ~40% of all patient
encounters were in their home.
Unwin BK. Am Fam Physician 2011

14. National Healthcare
Expenditure (NHE)
Forecast
Dan Munro, Forbes 2014

15. “The $2.8 trillion
US healthcare
industry is being
upended by
companies
attuned to the
needs and desires
of empowered
consumers.”
pwc. Health Research Institute April 2014. Healthcare’s new entrants:
Who will be the industry’s Amazon.com?

16. “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
national challenges of our time.”
Kathleen Sebelius, Former US Secretary of HHS
mHealth Summit December 2011

17. “Are you open to trying new, non-traditional ways
of seeking medical attention and treatment?”
pwc. Health Research Institute April 2014. Healthcare’s new entrants:
Who will be the industry’s Amazon.com?
83% of consumers
would be open to
new, non-traditional
forms of medical
care.

18. mHealth Technologies to Improve
Outcomes
1.What is mhealth , how did we get here, and
why should we care?
2.Examples of how mhealth can transform
healthcare.
3.Where is the evidence?
4.What will it mean for providers?

19. Eye / Ear
Smart Hearing Aids
Contact lens-based glucose sensing
Digital otoscope / fundoscope
Noninvasive Intraocular pressure
Automated refractive error
Miscellaneous
Pill-box & bottle sensors
Fetal monitoring
Posture / Position sensors
Activity monitors
Sleep trackers
Brain/Emotion
Wireless, mobile EEG
Head impact sensing
Noninvasive intracranial pressure monitor
Continuous sensing ANS activity
Stress recognition via voice / respirations
Heart / Vascular
Continuous & intermittent rhythm monitors
Noninvasive continuous BP tracking
Thoracic impedance (fluid status)
Handheld echocardiography
Stomach / Intestine
Esophageal pH sensing
Endoscopic image transmission
Medication compliance sensors
Fecal blood / bilirubin detection
Gut electrical activity sensing
Urine / Bladder
Comprehensive urinalysis
Genomic identification of STDs
Diaper-based sensors
Lung
Home Spirometry
Continuous pulse oximetry
Inhaler Utilization
Breath-based diagnostics
Breath sound detection
Environmental exposures identification
Skin
Surface & core temperature
Gross lesion assessment
Pressure sensing for wound care
Sweat chemistry
Epidermal electronics for plasma
constituents.
Blood
Continuous, noninvasive glucose
Point-of-care blood tests
Transdermal hemoglobin

20. mHealth for Chronic Disease
Management – The Beginning
Urine testing for glucose first available 1945.
1974 Reflomat – first evidence of home
monitoring lead to improved glucose control
Studies initiated in the 1970s found that tighter glucose control improves
outcomes, leading to a call for greater ease of patient monitoring.
Clarke SF. Br J Med Sci 2012;69:83-93

21. Diabetes Management Today
1. Over 25 million US adults have diabetes, roughly 8% of
the adult population, while an additional 79 million are
pre-diabetic. 1
2. The total cost of diabetes in the US for 2012 was $245
billion, with $176 billion in direct costs. 2
3. Interventions that train patients in self-management and
improve their communication channels with providers can
significantly improve outcomes and decrease costs. 3
1. CDC. National diabetes fact sheet: 2011.
2. ADA. Diabetes Care. Apr 2013;36(4):1033-1046.
3. Aubert RE. Annals of internal medicine. Oct 15 1998;129(8):605-612.

22. The Next Generation of Continuous
Glucose Monitoring

23. Hypertension Management Today
1. One of every 3 adults in America have HTN. 1
2. Nearly $100 billion in total costs are attributed to
HTN annually in the US. 2
3. Nearly 40 million office visits every year in the US
have a primary diagnosis of HTN making it the
single most common reason for an office visit.3
4. Less than half of all hypertensive individuals have
their blood pressure under control. 1
1. MMWR. Morbidity and mortality weekly report 2011;60(4):103-108.
2. Heidenreich PA. Circulation 2011;123(8):933-944.
3. National Ambulatory Medical Care Survey: 2010 Summary Tables.

24. Improving HTN Management Through
mHealth
• Home BP monitoring alone is
already known to improve BP
control, although only slightly.1
• When home monitoring is couple
with provider feedback and patient
engagement there is much greater
BP control than with monitoring
alone.2
• Cuffless and continuous non-
invasive BP monitoring devices will
soon allow for a substantially
greater depth of understanding of
BP and its control.
1. Uhlig K. Annals of Intern Med 2013;159(3):185-194..
2. Green BB. JAMA. 2008;299(24):2857-2867

25. COPD Management Today
1. 15 million Americans have COPD. 1
2. ~50% of Americans with diminished pulmonary
function do not know that they have COPD. 2
3. Total estimated costs of COPD is $38.8 billion (2005
dollars) with excess annual health costs per
individual with COPD vs. not of ~$6,300.3
4. A pilot RCT of connected care with home
monitoring of 80 COPD pts. found a non-significant
decrease in ER visits & hospitalizations.4
1. MMWR. 2012;61(46):938-943
2. Mannino DM. Arch Intern Med. 2000;160:1683-9
3. Foster TS. COPD. 2006 Dec;3(4):211-8
4. De San Miguel K. Telemed & eHealth 2013;19:652-7

26. COPD Management with mHealth
Faria I. Telemed & eHealth
2014;20:1-7

27. Acute Home Diagnostics - The Beginning
1. The e.p.t. home pregnancy
test was first marketed in
1977. “A private little
revolution.”
2. Today, approximately 20
million tests used annually
in the US with annual sales
of $227 million.

28. Upper Respiratory Tract Infection (URI)
Management Today
1. Viral respiratory tract infections, “colds” are the
most common acute illness in humans and the
most common reason for an urgent office visit. 1
2. Adults average 2-4 colds annually.
3. The estimated total annual economic impact of
non-influenza viral URIs is ~$40 billion in the US
alone.2
4. There is no role for radiologic or lab studies in the
diagnosis or treatment of URIs.
1. Cooper RJ. Ann Intern Med. 2001, 134: 509-517
2. Fendrick A. Arch Intern Med 2003;163:487-94

29. Potential mHealth Solutions for the
Common Cold
• iPhone-linked thermometer that
tracts symptoms, informs you of
others in same community with
similar symptoms, and sends
information to provider’s office
• Tyto handheld remote physical
exam linked to provider.
• In the near future, POC salivary
tests for home diagnosis of exact
pathogen.
Temperature
Mouth & Throat
Lungs
Ear
Eye
Heart
Skin

30. Urinary Tract Infections
1. Most common bacterial infections in adults. 1
2. Accounts for roughly 7 million office visits, 1
million ER visits and 100,000 hospitalizations
annually. 1
3. UTIs are responsible for an estimated cost of $2
billion dollar annually. 1
4. Only ~50% of women presenting with symptoms
concerning for UTI are actually diagnosed as
having one after evaluation.2
1. Foxman B. The American Journal of Medicine. 2002;113:5-13.
2. Bent S. JAMA. 2002;287(20):2701-2710.

31. mHealth Solutions for the Home Diagnosis
of UTI
1. Mohan R. PLoS One 2011;6(10):e26846.
• Several mobile devices are designed
for at-home urinalysis with analytic,
tracking and transmission capability.
• Future advances will likely allow for
the detection of both the presence
of infection and the exact pathogen
via a mobile electrochemical
biosensor .1

32. Otitis Media
1. Recurrent ear infection is the most common
acute complaint of children leading to ~30 million
pediatrician visits annually.1
2. Responsible for annual costs over $5 billion
dollars, not including lost work time by family
caregivers. 1
3. For every 100 children utilizing a healthcare
service because of their parent’s suspicion for an
acute ear infection, only 50 are actually
diagnosed to have an ear infections.2
1. Bondy J. Pediatrics 2000;105(6):e72.
2. Laine MK Pediatrics 2010;125(5):e1154-e1161.

33. Home Diagnosis of Otitis Media –
Smartphone Otoscope
•By giving parents the ability
to digitally image their
child’s tympanic membranes
at home with a smartphone-
based otoscope a substantial
percentage of office visits
could potentially be
prevented with remote
image transmission and
diagnosis

34. What our “Best Friends” can Teach
Us About Disease Detection.
• Dogs have, on average 170 cm2 of olfactory
epithelium relative to 10 cm2 in humans.
• They have roughly 200 million olfactory
receptors compared to our ~5 million.
• Their sense of smell is estimated to be
~1,000,000 x more efficient than ours.
• Prior studies have found that trained dogs
have > 90% accuracy for detecting cancers
in exhaled breath.
McCulloch M. Integr Cancer Ther 2006;5:30-39

35. 10 October 2012

36. Smartphone Breath Analysis for
Cancer Detection
Lung Cancer
Colon Cancer
Breast Cancer
Peng G. Nature Nanotechnology 2009;4:669-73

37. mHealth Technologies to Improve
Outcomes
1.What is mhealth , how did we get here, and
why should we care?
2.Examples of how mhealth can transform
healthcare.
3.Where is the evidence?
4.What will it mean for providers?

38. The Evidence for Connected Health
May 30, 1996
• 1396 veterans with DM, COPD or HF
• Over 6 months “connected” cohort had 68% more
PCP contacts and an average of 7.5 calls with a
primary care nurse c/w 0 in control cohort.
• Connected patients were much more satisfied
(p<0.001) but no difference in QOL.
• Connected patients experienced significantly greater
readmissions (p=0.005) per month and hospital days
(p=0.041).

39. The Evidence to Date
• 179 GP clinics in England, 3230 individuals with
DM, COPD or HF
• Intervention clinics incorporated mobile devices;
BP, pulse ox, scales, glucometers… plus symptom
questions and educational messages.
• At 12 months sig decrease in admissions (OR 0.82,
p=0.017) and unadj. mortality (OR 0.54, p=<0.001).
• However, the difference in admissions was limited
to only the first 3 months and was due to a marked
increase in control admissions.
• No change in PCP contacts, QOL or psychological
(anxiety, depression..) outcomes.

40. “…high quality
adequately powered
trials of optimised
interventions are
required to evaluate
effects on objective
outcomes.”
“The paucity of
evidence calls for
much needed future
research...”
“High quality trials
measuring clinical
outcomes are
needed.”
January 2013
January 2013

41. Incorporation
of mHealth
into Existing
Systems of
Care
Steam Engine Electric Dynamo
David Paul A. American Economic Review 1990;80:355-61
“Productivity Paradox”
Systems of care need to be re-engineered around
the capabilities that mhealth tools provide.

42. mHealth Technologies to Improve
Outcomes
1.What is mhealth , how did we get here, and
why should we care?
2.Examples of how mhealth can transform
healthcare.
3.Where is the evidence?
4.What will it mean for providers?

43. Transitioning from this….
…to this.

44. Healthcare Providers: Much Room for
Improvement
1. In general, physicians are unsatisfied with their careers:1
 Morale considered poor to very poor by 80% of physicians.
 Two-thirds would not recommend it to younger individuals
 One-third, if given the chance, would no longer choose to be a
physician.
2. ~80% of physicians rate the doctor-patient relationship to be
the most satisfying aspect of their work.1 However,
 Today, average face-to-face time with a patient is ~10 minutes2
 It would take between 11-18 hours daily for a PCP to provide
just the preventative and chronic disease management
required for a typical patient compliment. 3,4
1. http://www.physiciansfoundation.org/
2. Gottschalk A. Annals of family medicine 2005;3(6):488-493.
3. Yarnall KS. American journal of public health 2003;93(4):635-641
4. Ostbye T. Annals of family medicine 2005;3(3):209-214

45. What mHealth can Mean for Healthcare
Providers
1. mHealth technologies will dramatically change the
practice of medicine, which, at first blush is very
concerning to physicians.
2. However mHealth will eventually free physicians of
being directly involved in precision, algorithmic
medicine that currently takes up a majority of their
day.
3. Instead providers will regain their primary role as a
diagnostician and educator allowing for longer and
more rewarding interactions for both patients and
providers.

46. Wellness
Diabetes
Healthcare Team
Personalized Predictive Analytics
Learning Healthcare System
Physician (diagnostician,
educator), nurse,
pharmacist, dietician,
physical therapist, ITRespiratory
Home Diagnostics
Hypertension

47. Watson is now “…the size of three pizza
boxes stacked up. It's also 24 times faster
and has seen a 2,400 percent
improvement in performance.”
Based on my genotype and
sensor data, what is the
best treatment for me?
2012