mHealth Insight: the blog of 3G Doctor

At the recent Wearables Europe Conference in London I explained why I think mHealth is set to enable the transformation of today’s Electronic Disease & Billing Records into tools that are primarily designed to serve Patients.

I wonder if the $1.2Billion EPIC system bought by Partners will be the biggest EHR to ever be bought by a Hospital?

Related Post: Boston Children’s Hospital may want more apps but what’s stopping them from just buying them? (2013)

Held at ​Carton House (an 18th century Manor House 14 miles from Dublin that’s been converted into a Luxury Spa & Golf Resort) ​the​ ​Internet of Things (IoT) Summit is dedicated to bringing together corporates, entrepreneurs and investors to explore the business opportunities that are developing as everything get’s connected.

For an introduction/backgrounder on the IoT mHealth opportunity check out how embedded connectivity is already fundamentally transforming how Patients and Healthcare providers manage Diabetes – a chronic disease that accounts for an annual expenditure of more than $548 Billion.

Key ​​programme topics will include:

>​ The business case for IoT
> What problems can the IoT solve now?
> How can start-ups address big IoT markets?
> Is there ‘smart money’? If so, where is it investing?
> How will the IoT change business models?
> Who are the disruptors and who will be disrupted?
> Case studies & applications covering all of the greatest IoT-related opportunities, from the connected home, smart cities to mHealth.

Keynote speakers will include:

> Mike Byrne, CEO, GS1 Ireland
> David Doherty, coFounder, 3G Doctor
> Prof Willie Donnelly, President, Waterford Institute of Technology
> Barry Downes, CEO, TSSG at Waterford Institute of Technology
> Professor Linda Doyle, Director of CONNECT and Professor of Engineering & The Arts at Trinity College, University of Dublin
> Ludovico Fassati, M2M Vertical Market Dev, Vodafone
> James Finglas, Managing Director, MJ Flood Technology
> Ken Finnegan, Chief Technology Adviser, Irish Development Agency
> Jim Greer, Graduate Studies Centre, Tyndall Institute
> Adam Grennan, Country Manager (Ireland), Cisco
> Richard Linger, Director, TEC Gateway
> Helen McBreen, Venture Leader, National Digital Research Centre
> Philip Moynagh, VP of Internet of Things Group, Intel
> Paul Murray, Investment Director, Atlantic Bridge Capital
> Noel E O’Connor, Associated Professor, Dublin City University
> Gerard O’Keeffe, CEO & Co-founder, GeoPal Solutions
> Johnny Ryan, Co-founder, Toolkit.ie

My talk will be titled: “mHealth Insights into how Medicine is being transformed as the Internet evolves into a device dominated network” and if you refresh this post on the 17th June you’ll be able to view my slide deck & watch a video of my talk.

​Follow the event on Twitter #IoTSummit, register here on ​the IoT Summit website​ (​standard price is only €399.75 before the 11 June 2015 and €123.00 for Students and Startups) or contact Jackie Bryan (+353870557913/[email protected]). To sponsor or exhibit please contact Suzanne Brennan (+353879191292/[email protected]).

*** UPDATE MON 15 JUNE 2015 ***

Draft of the slides I’ll be using with my lightening speed talk:

The born mobile generation don’t understand medical devices that aren’t connected. They regard convenience to be a measure of the quality of the healthcare services they receive. When they order something they check their Amazon app just a few hours later to see when it’s arriving. They think that there’s nothing that a YouTube video can’t teach them. They trust social media more than the advice of Professionals and they’re prepared to hack their medical devices with advice from people they’ve only met on the internet. They expect interactions with Doctors to be documented.​ They don’t want Carers who still think office visits are the product that they make because they expect us to use the tools of our time as they are so aware of the human inefficiencies that they would like all their care to happen without going to the Doctors office…

We all need to appreciate that mHealth makes expensive, inconvenient & impossible health care experiences inexpensive, ubiquitous & super convenient because when you are asking ‘what are the benefits of a documented consult with a Doctor over a Video Call?‘ the born mobile generation are struggling to think of reasons why you wouldn’t want to video consult with a Doctor…

This interesting Open BMJ report from a team headed up by Prof Marianne Hester at the University of Bristol further validates the need for Carers to provide Patients with tools to share their important health information because it’s no longer possible to practice good medicine in 10 minute slots.

“During the same 12-month period, only two of 434 men (0.5%) had explicit partner victimisation or perpetration stated on their medical record, compared to 32 men (7.4%, 95% CI 4.6% to 10.3%) reporting this in the survey”

Although GP consultations still remain largely undocumented it’s rare for a week to pass without another highly regarded researcher or charity calling for Doctors to ask just one more routine question of their Patients and recently I’m noticing it’s even the Doctors encouraging their colleagues. Meanwhile at the coalface you have Patients queuing needlessly for hours and NHS GPs trying to be productive by seeing as many as 60 Patients a day in their clinic while others have posters informing Patients that they can only discuss one problem per consultation.

I think it’s easy to think of reasons why NHS Doctors aren’t going to be enthusiastic about asking sensitive questions about domestic violence/abuse (it’s probably the easiest way to get yourself reported to the Medical Council) but I see huge scope for interactive medical history questionnaires (like Instant Medical History the tool that is being used by us here at 3G Doctor and in the pioneering work of Dr Amir Hannan in the NHS) to contribute and help overcome the key challenges/barriers:

Time

If this research is at all accurate and anything like 1 in 4 men presenting to GPs would report that they feel that they’ve been in a DVA relationship if they had the chance what hope have we of using this information to improve the quality of outcomes if we’re going to rely on the most overworked, qualified and expensive member of staff to ask and enter this information into the EHR?

Literacy

“Participants: Male patients aged 18 or older, attending alone, who could read and write English”

I think the “could read and write English” requirement is interesting as there are lots of Doctors who are unknowingly consulting illiterate Patients and in a lot of cases it’s not being recorded in the Patients EHR. It’s also something that an online questionnaire can actually test for, assess and help initiate support for the Patient/Carers eg. to help the Doctor appreciate how literate the Patient is and refer them to adult education services etc.

Recruitment

“A total of 1403 of eligible patients (58%) participated in the survey and 1368 (56%) completed the questions relevant to this paper”

I think it’s very revealing that the researchers only approached “unaccompanied male patients” that didn’t appear to be “unwell” or “distressed” and yet half of the eligible Patients still declined the opportunity to participate. It would be fascinating to have more details on the Patients reasoning eg. Was it because it was a paper based questionnaire? Was it because the information was being shared with researchers and not just their trusted GP? Was it because the questionnaire seemed to be irrelevant to the reason they were waiting to see a Doctor? Was it because the content of the questionnaire wasn’t clear at the outset?, etc.

Need to personalise medical history taking questionnaires

As I explain in this talk I gave at Doctors 2.0 in Paris last year it’s important that we provide tools to Patients in advance of the consultation. We also need to appreciate that it’s impossible to know enough about the complex lives of our Patients before we consult with them so the whole idea of having Patients complete set questionnaires is a completely outdated approach that will invariably lead to really undesirable outcomes eg. uncompassionately designed experiences:

We need to be much more considerate of Patients needs because as we’ve seen with Patients refusing to complete “dementia questionnaires” many will have similar objections/resistance to completing “domestic violence/abuse” questionnaires honestly which will make them worse than useless.

Paper based questionnaires aren’t up to the task – history taking needs to be interactive

In the research paper it states that the surveyed men “did not know that the questionnaire would include questions on abuse“. I think this brings into play huge issues with trust and the researchers clearly appreciated these (the “questionnaire booklet contained a detachable information sheet with contact details of support services and national help lines. Respondents were also encouraged to talk to the researcher who recruited them if the survey raised issues that caused them concern“).

It doesn’t surprise me to read that the researchers found that only 56% of Participants completed the relevant questions as this is what happens when you’re not clear to Patients about why you’re asking things and what you’re doing with the personal information you’re gathering.

It’s important to appreciate that the type of questions that are valuable if you were consulting with a Patient who is reporting that they have been abused are very different to those you would ask someone who hasn’t been. With Interactive questionnaires Patients don’t have to waste their time or be distracted by having to flick through pages of detailed questions that are irrelevant to them and can be very distracting (eg. after a branched question about domestic abuse a parent might think ‘I wonder what I’d of been asked if I had actually told the truth and let the Doctor know I did smack my child just once when they were naughty’).

The report suggests that “While nearly a third of the men had experienced or perpetrated a negative behaviour from or towards a partner (or both), about two-thirds of these men did not think their relationships had ever been characterised by DVA“. Clearly the detection of such subtle differences isn’t going to ever be achievable if the Patient is completing paper based questionnaires unaided (eg. without a researcher with a clipboard) as it’s easy to imagine they might try and game their answers eg. skipping forward a few answers to see what else they would get asked if they gave a certain answer etc.

Crime & Punishment or Crime Prevention

As soon as Doctors start asking sensitive questions and recording answers about what might be illegal activities it’s important that they are doing it in ways that make it admissible to courts. To ensure that Doctors asking domestic abuse questions don’t end up spending long periods away from their Patients having ‘he said she said’ discussions in court rooms it might be an idea to have the questionnaires approved in advance by court/defence authorities so that they’re accepted, can be used and don’t require Doctors to be involved in yet more administrative work.

The paper links to lots of evidence linking post-traumatic syndrome, depression, substance misuse, etc with domestic violence. Clearly these are things that GPs see day in day out so I think it’s obvious that we need more support for the use of interactive medical history taking questionnaires from proponents of crime prevention initiatives eg. by getting adults to share earlier with their GPs in more honest and open ways we stand a good chance of helping Patients identify problem behaviour before it escalates into abuse/violence.

Questionnaires need to be made available to Patients before the waiting room

In 2015 Patients shouldn’t be required to sit in a waiting room to access the attention of a Doctor (something that should be incredibly obvious following annual flu seasons, etc) but it’s also interesting to note that the researchers also discovered another flaw with having Patients complete surveys in the waiting room.

“Men completed the survey while waiting to be called for their appointment and thus, had limited time to complete the survey and some were interrupted before completing it. All the data missing for this reason are, therefore, missing at random, justifying to some extent our imputation method”

With >95% of NHS Patients waiting to see a GP having access to the internet themselves or via a carer so there’s simply no reason we can’t use the tools of our time because it should be obvious that the waiting room isn’t the ideal place/time for medical history sharing. It’s also important to appreciate that Patients are much more likely to share sensitive information (on issues like domestic abuse) when they can do it at a time and place that they choose.

Another related issue I noticed with the design of this research is that it only surveyed “unaccompanied male patients” and they didn’t approach any that appeared to be “unwell” or “distressed“. If you can walk into a NHS GP waiting room and at first glance tell me who’s unwell or distressed you’re wasting your time holding a clipboard – you have a unique talent for people reading, give me a call and we’ll go bankrupt a Las Vegas casino…

Does my Doctor know something I shared in their waiting room?

“Data were entered from the paper questionnaire into an Access database. Only individuals who responded to all four questions on negative behaviours were included; two respondents were excluded because they were younger than 18… …Consent was sought from participants for access to their medical records”

No mention is made as to how personal medical information that was revealed by Patients in their GPs waiting room was shared with their GP. I can see we need to be very careful with this because for example if a Patient reveals they’re abusing alcohol (or worse still their partner) to the researcher and the GP says nothing about this during the consultation might the Patient leave with the impression that their behaviour is acceptable/tolerated?

Correlations

It’s unsurprising that a “strong association between negative behaviours consistent with DVA and mental health problems” was found in the research. I think this really highlights the compulsory need to incorporate clinically validated mental health questionnaires within any questionnaires that we put to Patients about Domestic Violence and Abuse (and vice versa).

What thoughts did you have on reading the paper?

With HealthKit engaging Patients (30+ million in the UK could use it today with their NHS GP) and ever more Healthcare Professionals signing up for accredited mHealth training I don’t think it be long for the tide to turn.

Doctors all have someone they can call when they need to ask medical advice (normally a work colleague or someone they went to college with) and the bosses of big healthcare firms have had this for years (2012) but with 64% of US adults having a smartphone (as of Oct 2014) I’m confident that soon we’ll be seeing Primary Care Physicians demanding that their Patients interact with them using their smartphones in between those increasingly redundant rushed office visits.

HatTip (for the original ‘you can’t list your iPhone as your primary care physician’ cartoon): Eric Topol

Related: Don’t miss the talk I’m giving next week at the Wearables Europe Conference in London on “How Wearables will transform the EHR (Electronic Disease Record)”.

“Transforming Medicine: Evidence-Driven mHealth” will be the focus of the first Scripps Health Digital Medicine conference to be held from Wednesday 30 September through to Friday 2nd October 2015 at the Scripps Institution of Oceanography Sea Side Forum (click here to view the detailed .PDF event programme).

The course is designed to explore the clinical evidence necessary to help jumpstart efforts to drive widespread incorporation of evidence-based mobile health solutions for more-personalized, individual-centric care to improve outcomes, advance satisfaction and decrease costs.

Key topics will include Patient-centered healthcare, Transforming healthcare from the inside out, re-Mixing primary care, Virtual healthcare, ordering up a house call, precision Medicine as a national initiative: The role of mhealth, What will Dr Watson mean?, personalizing predictive Analytics, the perils and promise of mHealth Big Data, employee health, the individual as Their own coo, Bringing the provider to the patient, consumer retail Setting, providing What the patient Wants and needs
individualizing Medicine, Transforming medicine: Evidence-Driven mHealth, if we measure it we can change it, Virtual reality at home, Transforming heart Failure care, mhealth in obesity Treatment/prevention, can tracking stress change it?, regulatory hurdles; Balancing Snake oil and innovation and The Apple of healthcare.

The impressive line up of already confirmed speakers includes:

Richard J Boxer MD, Chief Medical Officer, Pager
Deepak Chopra MD
Gary Conkright, CEO, physIQ
Drew Conway, Head of Data, Sum
Robin Cook MD, Physician and Author of “The Cell”
Zubin Damania MD, Founder, Turntable Health
Walter De Brouwer, CEO, Scanadu
J Thomas Heywood MD, Scripps Health
Don Jones, CEO, Trial Fusion
Ilene J Klein MD, Global Employee Health Services, Qualcomm Life
Santosh Kumar, Mobile Sensor Data-to-Knowledge Centre NIH
Anna Mccollister-Slipp, Participatory Research, Scripps TSI
Jessica Mega MD, Google [X]
Rob Merkel, Healthcare & Life Sciences, IBM Watson Group
Wendy J Nilsen, Health Scientist Administrator, NIH
Babak Parviz, Professor, University of Washington
Adam Pelligrini, VP Digital Health, Walgreens
Rosalind W Picard, Professor of Media Arts and Sciences, MIT
Amir Dan Rubin, President & CEO, Stanford Health Care
John Sculley, former Apple CEO & mHealth investor
Jeffrey Shuren MD, CDRH Director, FDA
Donna Spruijt-Metz, Director, USC mHealth Collaboratory
Steve R Steinhubl MD (Course Director), Cardiologist
Eric J Topol MD (Co-Course Director), Cardiologist
Chris D Van Gorder FAche, President/CEO, Scripts Health
D A Wallach, Investor, DronDemand
Henry Wei MD, Clinical Innovation, Aetna
Brenda K Wiederhold, Owner, Virtual Reality Medical

Get involved

Registration starts at a very reasonable $345 ($75 for students) so waste no time registering at www.scripps.org/mHealth as this will no doubt sell out very quickly.

If you would like to exhibit at the event contact Corrine Yarbrough (+1.858.5545742 /[email protected]). Click here for more info on Scripps Health’s Translational Science Institute.

Related: Find a mHealth event near you on this global listing of mHealth events for 2015.

While giving workshops to Clinicians (like the mHealth course I developed with the Healthcare Informatics Society) I’ve noticed a big challenge is their preconceived ideas about how prepared and accepting Patients are about self monitoring.

Many have preconceived ideas that while this might seem like a good idea to kids sitting around on beanbags in Silicon Valley it’s completely out of touch with the reality that they are seeing as a Clinician who has spent their entire working life trying to get Patients to better manage conditions like diabetes with clumsy unconnected data generating sensors within a sickcare systems that are invariably all geared to just intensifying the treatment.

GBS told us “Progress is impossible without change, and those who cannot change their minds cannot change anything” so I thought I’d share a little trick I use to try and change minds as I imagine there are others out there faced with similar challenges as they too try to fire others up about mHealth.

First up introduce the group to mobile as the newest mass media by having them watch a high energy video of mobile industry guru Tomi Ahonen doing his magic (obviously hire him to give it in person if you can possibly afford it). Afterwards do a 30 minute discussion and have a long coffee break so that they come back getting how all digital is converging to Mobile. I think this lively Cape Town evening one is great but he’s given hundreds of talks like these all over the world that you can easily find on YouTube:

After this try and get the group to think about something abstract involving technology where they don’t have deep subject matter expertise and haven’t already formulated opinions (eg. drones, driverless cars, AI, etc). Be sure to introduce the product with a well detailed promotional video about the product. The purpose of this is to help them look at things differently, be more open to challenging views, shift their focus from problems to solutions, etc.

Get the group to then openly think about and list the pros and cons (eg. for driverless Google Cars all the usual stuff like improving road safety, productivity, listing examples like taking kids to after school clubs and adults to social events, increasing the utilisation of resources, etc and big brother knowing where you go, sameness/feeling of being a bee in a colony, remote delivery mechanism for anonymous killer drones, etc) and list these on a flipchart before posting to the walls.

Now start getting the group to come up with suggestions for ways that the barriers can be overcome. Eventually you let them get to or coax them to a point where they suggest solutions (eg. that the driverless cars become public transport, pay as you go so no one owns them, they become the remote eyes of law enforcement so that they don’t give rise to 21st century Dick Turpin’s/even people who don’t use them benefit from the CCTV public safety and crime prevention, etc, etc).

Now post all those workings on a wall and turn the topic to what the group thinks needs to be done to change their perceptions of seamlessly connected medical devices and of mobile phones when they are so smart that they are seamlessly and intimately monitoring our health us as we go about using just them normally.

Fire the audience up by asking them to think about how documented care changes everything, the future of Health Insurance and clinical trials.

As the course leader watch this video about Medical detection dogs so you can get your head around Disco Dog Coats as that makes a good starting point and be sure to have mHealth tech in your pockets to demo to the group the technology that is already being used by Doctors who are adopting mHealth to delight their Patients (the Alivecor ECG is great for this as are the rich high quality educational apps from the likes of 3D4Medical but for more ideas check out the Smartphone Medical plenty to find here and discover plenty more ideas here).

Let me know how you get on and please share with me any ideas, tips or tricks that I might try or that you’ve found useful.

One last thing: Don’t forget most Clinicians learnt to do their job when…