How Mobile Technologies Fuel TeleHealth Advances

This article appears in the September 2012 issue of HealthLeaders magazine.

Ever since the first experiments with telemedicine, providers have been taking steps to move healthcare closer to where patients live and work. Now, mobile technology—epitomized by the millions of such apps already downloaded to smartphones, but also appearing in nearly unlimited form factors—is accelerating those steps.

At Boston's Partners HealthCare, a system with 2,700 licensed beds, 45 employees scrutinize these developments at the Center for Connected Health. One early effort to equip cardiac patients with remote monitoring technology resulted in a 50% drop in readmissions, says Joseph Kvedar, MD, founder and director of the center.

"We're all committed to a healthcare delivery model that moves care out of the hospital, out of the office, and directly and continuously into the lives of patients," Kvedar says. "We find that the best technologies to facilitate that vision are monitoring and communications technologies properly applied."

Kvedar says his team sees "two reproducible value propositions over and over again" regarding mHealth. One is improved patient self-care. "That to me is the most exciting one, that we can arm patients with data about themselves in context, and they manage it not dissimilar to the way a baseball manager manages a lineup of batting averages. They can see what they're hitting and if they need to improve something. They can do that and watch their numbers change. It's very, very powerful."

The second value proposition, Kvedar says, is just-in-time care. "We give providers a dashboard view of their population, informed by all of these sensor data, connected health data that are streaming in from those patients, and then enable those clinicians to reach into the lives of individuals who need the most at that moment in time," he says.

The sheer power of smaller, cheaper, and faster healthcare is evident in today's mHealth solutions; dermatology, Kvedar's specialty, has been an early beneficiary. "When I started doing this work, the camera we used was a $12,000 device that was about the size of a shoebox, and it had less than one megapixel resolution," he says. "Now you can do everything on your iPhone or your Android smartphones, so teledermatology is coming into its own. We finally are at the point where the technology to effect image capture and history entry is so easy that anyone can do it on the fly, and the amount of incremental time that the referring provider needs to put in is almost zero."

The cardiac patient remote monitoring app Kvedar mentions happens to be delivered in a tabletop device made by McLean, Va.–based ViTel Net, which is owned by the Bosch Group, but only because that patient demographic is less comfortable using a tablet or phone interface. But more and more, tablets and phones are the form factor of choice, Kvedar says.

Despite some continuing data breaches, security of health data on mobile devices is improving, Kvedar says. "I think it's a solved problem, to the degree that any information these days is always subject to being hacked," he says. "You can never say glibly, ‘That'll never happen,' but we use secure sockets, we use all kinds of authentication tools, we make sure our vendors pass a very rigorous security audit, so we're very particular about privacy and security and take it very seriously so that we can protect and maximize our patients' privacy. I don't see it as a big barrier."

In an age where "there's an app for that" is a catchphrase, healthcare is grabbing its share of the spotlight. At the Consumer Electronics Show in January, Eric Topol, MD, chief academic officer of Scripps Health, a five-hospital, $2.5-billion nonprofit health system in San Diego, made headlines by appearing during a keynote speech and recounting his use of an experimental device, the AliveCor iPhone ECG.

Doubling as an iPhone case, the AliveCor ECG includes two outward-facing sensors. "You just make a circuit with your heart," Topol told the CES audience. The phone displays the patient's cardiogram. "I use it in clinic now all the time for my patients instead of a regular cardiogram."

Topol went on to tell the audience that he was on a cross-country flight while carrying the device. "They called for a doctor on the plane for a passenger in the back," he said. "With this phone, I could make a diagnosis of a significant heart attack, which led to an emergency landing, and fortunately the fellow did very well."

As of mid-August, the device was not for sale and its website stated that it was "Not cleared by the FDA for sale in the United States." A spokesman for Topol said that patient privacy prevents Topol from revealing any other details about the incident.

But the ripple effect from stories such as Topol's are being felt throughout healthcare, and the "cool" factor of providers developing their own apps is thrusting them into entirely new spotlights.

At the Apple Worldwide Developer Conference in San Francisco in June, the new Mayo Clinic Patient App— which lets Mayo Clinic patients access their personal medical record, appointment schedule, and other services—was highlighted by Apple.

With more than 4,000 physicians and scientists, a 140-year history, and more than 1 million patients seen annually, Mayo has its own team of 60 people—including designers, project managers, physicians, and nurses—working in its Center for Innovation.

"We have a declared mission to touch in a meaningful way 200 million lives," says Michael Matly, MD, director of business development and new ventures at Mayo's Center for Innovation.

"Unlike other innovation centers in academic medical centers, we focus strictly on health delivery, so our motto is transforming the experience and delivery of health and healthcare," Matly says. Mayo Clinic also partnered with Rock Health, a San Francisco–based incubator for startups led by CEO Halle Tecco. Many of the startups are building on mobile platforms.

"You really have a multitude of industries intersecting, so [Tecco] was able really to bring all these different groups around the table," Matly says. "You have payers and the venture community and technology companies and providers all coming around looking at these new technologies and health tech companies.

"We sift through this large list of startups and we pick a handful of them where we think there's an opportunity for Mayo to add value, so we basically match these companies with clinical champions within the practice that can work with these technological entrepreneurs to build better products."

Both Partners and Mayo are also wrestling with how mHealth apps will be financially supported in the post-fee-for-service world now unfolding.

A part of the solution may be to leverage mHealth to reduce the number of doctor visits and hospital admissions. Matly points to technology from CellScope, a San Francisco–based startup that provides a small iPhone attachment that turns the phone's camera into an otoscope. Sixty percent of pediatric visits are due to ear pain, but CellScope's technology would allow parents to snap what Matly calls "beautiful" in-home pictures of their kids' eardrums, then send them to doctors for diagnosis.

"A payer would be very interested, because if I can reimburse you $40 instead of going in for a $200 visit, it's probably better for me and better for the patient," Matly says.

Providers see mHealth as a way to keep out of the hospital patients upon whom they are losing money, such as Medicare patients, says Christopher Wasden, global healthcare innovation leader at PwC, a leading advisor to public and private organizations across the health industries.

According to a study published in March  by the Geisinger Center for Health Research (part of the Danville, Pa.–based, $2.7 billion integrated health system), the Geisinger Monitoring Program interactive voice response protocol reduced 30-day hospital readmission rates by 44%. Wasden says this lightweight approach succeeds where more tech-intensive telemonitoring solutions have proven inconclusive.

Still, there is resistance to mHealth. Wasden mentions a large healthcare system that told him that such change would require  a substantial change management program that includes educating physicians and nurses on how to deliver this type of care, and then changing their work flow so they can do it.

Beyond these leadership challenges, many providers are not prepared to accept the massive amount of new data generated spontaneously by sensors, then uploaded from apps on mobile devices to their data centers, Wasden says. "Doctors are already overwhelmed by the data they have. They don't want more data. And they especially don't want more data generated by a patient where they don't even trust the data that the patients generate. So while there's a lot of promise associated with the data, we don't actually have the tools and the capabilities and the applications necessary to really know what to do with the data to actually have it be of any value or meaningful use within the practice."

The disruption that truly mobile telemonitoring will inflict on healthcare goes deeper, Wasden says. "Doctors are very comfortable making gut decisions practicing medicine on an empirical and an anecdotal basis, but they're not comfortable saying that, ‘I made this decision based upon an analysis of the data that says that you have a 98% chance of doing better if we do this than doing that,' " he says.

Speaking for himself and not for Mayo, Matly expects direct-to-consumer payment to closely track mHealth technology adoption, while Kvedar sees the system working itself out somehow.

"Providers of all stripes, dermatologists included, are now open to different models of care delivery," Kvedar says. "They're more likely to say, ‘Okay, what we're going to do is concentrate on doing the right thing, and because these reimbursement models are changing, we have the faith to figure out that we'll be able to get paid for our work.' "

For now, mHealth has yet to approach the fullness of its promise.  But the way forward may be getting clearer with time. "In Massachusetts we are going at risk with every single payer in our system," Kvedar says. "We also already have a signed contract with BlueCross of Massachusetts that puts us at risk, and we're negotiating with all of our other payers, so we're changing the mind-set of our organization to be less focused on volume and more focused on value. As we do that, tools like connected health become
very appealing."


Reprint HLR0912-6

This article appears in the September 2012 issue of HealthLeaders magazine.

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