This post follows a testing period of the AliveCor ECG device in a wide range of test environments. If you’re unfamiliar with this remarkable innovation please read this post detailing my initial thoughts and watch the following video introducing the Alivecor iPhone ECG:
THE IMPORTANCE OF CLINICAL LEADERS
It’s quite obvious to anyone who has met Dr Dave Albert (founder of AliveCor) that he’s lightening years ahead of his peers. Whilst technologists are seemingly preoccupied with selling hats to one another, Dave operates at the place where the rubber hits the road.
Whilst I don’t want to in any way dismiss the fundamental importance of the growing legions of mHealth advocates who have marketing, business, telco, social media and electronics backgrounds who have lots of important work to do in convincing Mobile Operators that mHealth presents a consumer business opportunity because so many of them don’t realise this eg. O2 UK/Telefonica recently repositioned it’s new health unit O2 Health as a GP software provider of sorts (a significant change in direction from the ambitious high stakes plans it announced only 6 months ago). In my experience it’s critical and urgent for mHealth to find support from a key group of clinical domain experts (like Dr Albert) who can endorse these technologies to their peers before we’re going to see the majority physicians feeling confident about committing their patients care to mHealth solutions.
APPRECIATE THE SCEPTICISM FOR MHEALTH AMONGST MEDICAL EXPERTS
It’s quite obvious we’ve gone beyond the “toy” stage (companies like AirStrip Technologies have seen to this) with mHealth but it’s the next phase that in my opinion will be most difficult and protracted.
To give you an idea of the sense of the challenge, St Jude Medical’s SVP Neal Eigler MD,
who spoke on the same panel as Dr Albert at the recent TCT Conference I attended in San Francisco told the audience of his companies interest in mobile because it could offer an “incremental opportunity to improve patient outcomes”.
This really is analogous to the market leading watch (eg. Casio) or camera (eg. Polaroid) manufacturers who in 2000 were still uncertain whether mobile would ever substitute their devices. Please be assured if you make an electronic device the cannibal of cannibals will/is coming for your market next…
Of course you could argue that it’s best for us to just let this disruption happen and let these brands wither as they miss out on the opportunity but in my opinion the protracted sales/education cycles and specific Healthcare expertise within these companies makes it much better if we can have moves forward led by collaborative efforts between device makers and service providers.
I also think this is compatible with the medical device company business models eg. letting them use their expertise to be a part of the solution to existing healthcare problems rather than just resisting the device succession that will happen otherwise.
MOVING ON FROM MHEALTH CONFERENCES WE NEED TO LAUNCH AN ENGAGEMENT OFFENSIVE
As the person who predicted the emergence of mHealth events (and helped start the first together with Informa – Europe’s leading Telco/Medical Publihser/Event organiser) it comes as no real surprise that nearly 4 years later I’ve counted more than 70 in 2011.
This isn’t a bad thing. There are lots of conversations and debates that need to be had at a global and local level before mass market adoption of innovations can be expected. Events help to increase the organisation of an industry and the financial support (sponsorship money etc) being thrown behind mHealth events by firms such as Vodafone, AT&T and ChinaMobile indicate the strong levels of interest from each side of these converging sectors (Health and Mobile).
But the real challenge for me remains: we need to start either taking clinicians to these events OR taking stories of mHealth innovations to where the clinicians are. From my perspective Dr Albert is doing both and the mHealth market will be boosted no end if we can identify and elevate awareness of similar efforts by clinicians.
If you disagree with me consider this. There wasn’t a single practicing clinician attending the recent Mobile Healthcare Industry Summit in Brussels. Conversely at the recent Telecare and TeleHealth Conference that I spoke at in London (the biggest telecare event in Europe attended by 800+ delegates) there wasn’t a single delegate from a mobile operator (despite it being held a stones throw from the office of the mHealth team at the worlds largest mobile operator).
OUTLINE OF HOW WE’VE BEEN USING THE ALIVECOR DEVICE WITH CONSENTING PATIENTS
Currently the back end of the AliveCor service is developing in the best possible way: based on feedback from users. It’s now very elegant and easy to use. For the purposes of putting the technology to work out in the community in the UK/Ireland there are some regulatory issues we had to adhere to but in general the reports are sent up to the AliveCor server where cardiologists can read them and provide feedback. We then provide patient information through the 3GDoctor.com website using the patients name, mobile number and email address to register them (long random one time use passwords are automatically generated and sent to the patients email account).
In brief here’s an outline of the process we’ve been using with the Alivecor ECG device:
1) Hand the patient a smartphone and play a mobile video to them. This features one of our Doctors explaining what the device is, how it works and cautioning them as to the novel experimentation stage that the device/service is at, the fact that it will not effect their health and that they should not feel under any obligation to continue, that they shouldn’t consider this to be a NCT/MOT for their heart and should not put off seeing a Doctor because they’ve used this device. We also explain that by using the device they’re also helping with the development of this new technology. The video also shows them how I’d like them to hold the device and for how long.
2) After agreeing to proceed the Doctor snaps their picture and their business card (if they don’t have one they have them write their name/email/number on a piece of paper and snap a photo of that instead).
3) Make them comfortable and then hand them the device and have them hold it steadily
4) Automatically the results are recorded and uploaded to the remote server.
5) The session is finished and the Doctor can review the ECG and the readings are also read by a remote cardiologist.
6) If there is any concern this is either noticed by the Doctor or highlighted by the remote cardiologist on the Doctors account.
7) Using the time stamp the Doctor can identify any particular patient for follow up.
8) Doctor calls the patient, explains the concern and tells them to sign into the 3G Doctor account we’ve set up for them to complete a questionnaire and to download their consultation report containing the information they should show to their Doctor.
9) The Doctor checks back with the patient in 7 days to confirm they’ve followed up and to get a progress report.
WHY WE HAVE TO APPRECIATE THAT THE ALIVECOR DEVICE IS TRANSFORMATIONAL
A major problem I notice with new mHealth concepts is that people try to apply them to situations that went before as it’s easier to consider this than the moving goal posts that their existence may have created. I’ve noticed that incredible mHealth innovations can be prolific failures when you try to do this and the innovation from Alivecor is no different. This article by Ariel Schwartz at FastCompany (who has also been lucky enough to get early exposure to the device) highlights this brilliantly.
I can’t see how anyone thinks it fair or sensible to compare this innovation (and the new opportunities it will create and empower) and continuous monitoring services prescribed by a Doctor (which are already widely available). To me it’s as nonsensical as comparing a Rolls Royce and a Yacht as it’s futile to ask yourself which is actually better because they are different.
Each has different merits and disadvantages when placed head to head, but they aren’t going head to head because:
a) the Alivecor device doesn’t need a Doctor to be convinced to supply and prescribe it to a patient
b) the Alivecor device is really cheap and much more accessible
c) the Alivecor device needs little/no training to get results
The Everist Genomics device is capable of helping one person a day who is already being investigated by a registered Doctor who is thinks the patients heart functioning needs further investigation and has already been convinced to buy this device to use with their patients.
On the other hand the Alivecor helps an unqualified health worker screen an entire workforce in a afternoon. It works were there is no care system which is a system familiar to most people in the world. It’s worth being mindful that for most people in the world it’s not about good care or bad care it’s about any care and this isn’t always a developed Vs undeveloped world thing related to money (or the lack of it) because many adults who have health insurance/coverage have their own personal issues that deter them from proactively seeking health advice and information.
THE REAL OPPORTUNITY PROBABLY STILL REMAINS OBSCURE
AliveCor’s device opens up new opportunities most of which we never had before. Just like we found when we launched 3G Doctor there is nothing as enlightening as actually launching something and making it available to patients and clinicians to experience.
I’m particularly interested in mHealth when it stops looking like “Healthcare” and starts looking like “something we just do so”. Here’s a few new possibilities that the device/service have already got me thinking about:
a) Integration to other devices
I see no reason why this isn’t being embedded into training bicycles, health kiosks, games consoles (to help make it all extra physical). Imagine the potential for your ECG to act as an access key to your car? Imagine the security advantages such a key could have for specific locks eg. the ignition key on a cash in transit vehicle (where you might not only want a specific driver but also that he only allowed to drive it in a relaxed state? Imagine a mobile phone that just recorded this data as you held it during normal use? Imagine the potential for Health by Stealth with subtle screen color changes making you more aware of your stress levels? Imagine salespeople using these devices to influence their behavior so they do more business (“keep it grey to make a sale today”)?
b) Opening up the APIs for game developers.
We’ve been looking at this area for some time (if you’re interested in commercial opportunities I’d thoroughly encourage you to connect with HealthSmart – developers of the Smart Agent app). How about a James Bond game where you need nerves of steel to stay tool and win the game of Poker at the Casiono Royale? How about a “go to sleep” app that’ll help you unwind by hitting mental goals.
I imagine answering a variety of sensitive questions might get very challenging when some canny developer get’s around to twinning this accessory to a “lie detector” app…
c) Employee wellness programs
With ever increasing levels of home and out of office working I think it’s interesting to think about the ability for technology such as this integrated into mobiles to deliver a key engaging component to employee wellness programs helping to not only manage stress but also to help lone workers optimise their call performance via biofeedback mechanisms.
TRUST: THERE ARE DIFFERENT RULES FOR DOCTORS
One week with the AliveCor ECG and I had an experience that for me highlights the trust patients have with Doctors that is all too often ignored/overlooked by technologists. I met for an after work drink with a leading consultant cardiologist and after a few trials he insisted that I let him borrow the device because there was no time to get him his own one.
The next morning I’m at a client meeting and a customer asked me where’s your ECG phone? I explained that I gave it to the consultant I met with last night. The following conversation then happened:
“What you gave him your mobile? with your SIM card in it?”.
“Yes i just diverted all my calls and texts”
“But what about all your pictures and personal stuff?”
“Well he’s a consultant Cardiologist so even if he did look it wouldn’t matter that much”
“Are you sure he’ll give you it back?”
“Well he’s a consultant Cardiologist and and he said he would”
“What so you’d trust any cardiologist with your personal phone?”
“Any cardiologist I properly know yes”
“What did he need it for?”
“A game of golf with colleagues”
“Would you let me borrow your personal phone?”
“Ok you can but only once you’ve actually saved the life of a friend or member of my family OK?
The IT guy was perplexed by this but I think it really highlights the trust patients have with Doctors. Yes for me there is really only one person I’d trust with my mobile: my Doctor.
THE IMPACT OF INSURANCE ON INTEREST IN SCREENING
I found a very interesting difference between Irish and British patients. The Irish patients with private insurance showed a reluctant to test that I never saw with a British patient (who can access the free NHS services) that seemed to be because of a fear of increased insurance premiums as a result of being “medicalised”.
LESSONS FROM A REMOTE PATIENT EXPERIENCE
Note: this is an actual patient experience but the patient has agreed for us to share details of it here as it highlights a multitude of the issues diagnostic mHealth devices face. We’ve taken it upon ourselves to strip out anything that might identify the patient.
1) Patient took printed information to their family Doctor and had an awkward conversation where the Doctor initially made them feel uncomfortable for “going private” with a diagnostic test
2) On learning that the test result (which was brought to the consultation printed out) was produced using a hand held device the Doctor asked when this was done and was taken aback on learning it was at “a dinner party”. “So you’re telling me you’re going to a dinner party where people get ECG’s done? Where did you find this?”
3) “So who’s the cardiologist who read this ECG?”. Well I never met the cardiologist he just fed info back to a Doctor (who’s name/registration number is on the top of every page) who then called me and told me to go online and print off this report and give it to my GP”.
4) “Oh I see, please excuse me this is definitely a first for me! ha ha”
5) The Doctor then proceeded to take the patients hand. The patient thought it was an act of kindness and was pleasantly surprised. The Doctor then asked if she felt okay as she was in a AFib right now. The Doctor then proceeded to conduct a blood pressure test and got a reading of 160/80.
6) The patient was referred immediately to a specialist unit. Had it not been for the test this patient reported that they would never have gone forward for a health check as they’d “never had any health issues”.
7) The patients primary care Doctor got in touch with us and we had a very interesting conversation. Following this up they provided us with half a dozen really good ideas about how we could add value to the patient documentation we had provided to the patient.
WHAT DO CLINICIANS THINK OF THIS DEVICE AND PATIENTS IT CAN REFER?
So I’ve met with and shown/demoed the Alivecor device with a wide range of medical and IT professionals. Everyone from the lowly medical student and software developer right up to the practice nurse and Hospital consultant and it’s clear that it divides opinions.
“Unneccessary”: a large number of Doctors think it’s an unneccessary procedure that will lead to pointless concerns amongst patients who would be better off not knowing. Some compare it to the Baby Ultrasound DVD services that GE used to offer in USA shopping malls.
“A device that will increase healthcare expenditure”: a few Doctors think this will drive increased numbers of cardiac referrals and increase healthcare expenditure within the NHS. Individuals who think this are ignorant of the opportunity and the long term costs/loss of productivity associated with poor treatment eg. the £8 billion annual cost to the British economy as a result of strokes
“Lifesaving”: the majority of those who are medically trained can see that this device gives a skill that they already have (to accurately feel and measure a patients pulse) to other carers and could be a lifesaver
“Something I want”: a large proportion of healthcare providers appreciate this would be a great consulting tool. Several mentioned that the credit card sized sensor would be cool way to occupy patients when they are inputing data into their EHR’s.
“A very interesting care management tool”: a Cardiologist explained to me how the increasing success of CVD treatments are now impacting on primary care as GP’s and increasingly responsible for the long term management of a patient who’s primary treatment may have been several years ago.
“A nice way to ration”: some healthcare payers told me that tools like this on a Doctors belt are going to become very important as GPs come under wider criticism for rationing of care (and this is before GP Commissioning comes into force!). I think it’s easy to see the opportunity for improved documentation and reassurance this could provide.
“Unethical”: I found it interesting that several people noted that in some markets unscrupulous employers may use this to screen prospective employees (so they avoid hiring/training those with health problems) or that some men may use it to screen the health of prospective brides.
“Can you imagine what we can make with this?”: mHealth leaders see a cascade of specific opportunities from a game to count sheep and send you asleep (speed controlled by your Heart Rate of course) to a stress management program.
“Wow I need the API for this OK?”: software developers want to make games with this device.
Please feel welcome to share your thoughts in the comments below…
MY PERSONAL TAKE AWAY…
Smartphones featuring mHealth technologies such as ECG will increasingly come to transform the point of care and connecting specialists to members of the public in a variety of new times and places. These represent exciting new opportunities for Healthcare professionals to add value to peoples lives but it’s first going to force a reform of the conventional short, rushed, uninformed (eg. in-person taking/documenting of the patients history) and largely undocumented Doctor consultation process that continues to fail Patients, Doctors and care providers.
As Dr John Bachman, Prof of Primary Care at the Mayo Clinic, has already shown us the conventional Doctor-Patient consult isn’t up to the job of even managing the needs of patients who present with information they got off the web. New diagnostic technologies are only going to make the limitations more pronounced but they’ll continue to fail us until we accept 3 staples for moving forward:
1) Patient accessible electronic healthcare records.
2) Patients need to be provided with access to interactive patient history taking tools so they can effectively be listened to (= share their problems, issues, concerns, websites and diagnostic data) by their carers.
3) Doctors need to be able to find a way to let their patients interact with them (or their colleagues) digitally.
If you think patients can’t give their history online go and look at the stats which will show you how many seniors are already booking and paying online for holidays, insurance, train tickets, taxes etc. or using social networks and Skype to stay connected with distant relatives and friends.
If you think consumers aren’t going to be buying medical devices for their own personal use visit an Apple retail store and look at the connected BP Monitors, Weighing Scales, thermometers, pedometers, activity/motion sensors, cameras, etc that are already on sale.
In 2012 the AliveCor ECG will be on sale in stores and I have no doubt we’re going to see a long line of smart medics queuing up to buy them…
****************UPDATE APRIL 2013*****************
****************UPDATE APRIL 2013*****************