Medical Futures Lab

Now that our class is coming to a close, and given the amazing presentations and responses at our final critique last night, I thought this article in the Boston Globe was particularly appropriate.

Entrepreneural spirit just a start to “disrupt” health care – http://www.bostonglobe.com/business/2014/04/25/more-than-entrepreneurial-eagerness-needed-disrupt-health-care/POSS7fv6mBZQPGfhojuO7I/story.html

The article talks about the recent boom in hackathons, accelerators, and showcases specifically relating to health and medicine. There are tons of new startups and products that are coming out with the potential to change medicine, but they are all running into the same problem.

Once you’ve built an app, or built a device, in order to validate it you need to do some sort of pilot study. But it turns out, health startups are finding it extremely hard to find doctors and hospitals willing to work with them on a pilot-study.

The reason isn’t that doctors don’t want change, but it’s because they are already extremely busy people. In almost every field there are dozens of apps claiming and trying to do the same thing. So in an extremely limited time resources setting it becomes very hard for doctors to decide whose product they should pilot.

Not only that but hospital systems are extremely bureaucratic, institutional review board approvals can be hard to come by, and clinical trials can often costs startups easily between 50 – 100k!

All of that made me realize how lucky we are in our medicine in media class to have problem owners who are so invested in the products and teams. We don’t have to struggle to find a physician partner, because we already have an in-built one.

Creating a medical product is far from an easy pathway, but since all of us are lucky to have one of the biggest obstacles in our path cleared, I hope to see several of our innovations in the real world in the near future.

As we continue to develop innovations in mobile health technology, one of the first questions that needs to be asked is “Who’s paying for this?” Effective mHealth campaigns should be tailored to their target audience, which requires preliminary research about the platform and its potential, conducting focus groups, and multiple rounds of pilot testing.This costs money, and most industries want to see profits in a timely manner. In answer to the growing interest in mobile health, the National Institutes of Health (NIH) has developed two grants to fund mobile health aspirations. Specifically, these grants are aimed at “utilizing mobile health tools aimed at the improvement of effective patient-provider communication, adherence to treatment and self-management of chronic diseases in underserved populations.”

The article I read, which outlined the NIH’s plans entitled “NIH grants to fuel adherence, patient-provider communication” initially caught my attention due to its direct alignment with the interests of my MMAL group: patient adherence and patient-doctor communication. In order for patients to adhere to their treatment plans, it is important for them to feel engaged in their health. The NIH notes the potential of mobile health to “educate patients about the importance of sticking with treatment regimens and changing behaviors,” a promising avenue to improving adherence.

These grants simultaneously address the need for increasing mobile health use and the importance of patient-doctor communication to foster patient adherence and better health outcomes. However, what makes these grants stand out to me as relevant is their direct address of “underserved populations.” It is all too easy to overlook the destitute when visualizing shiny new mobile health technology innovations. However, these populations suffer the worst health disparities, especially for chronic health conditions and could stand to benefit (possibly the most) from mobile health innovations. In its quest to serve all populations, the NIH also addresses one way in which they plan to avoid using mHealth to marginalize other populations. Specifically, they hope “to transmit patient data digitally from remote areas to specialists in urban areas,” taking advantage of the growing wireless infrastructure available to the population.

Finally, the projects funded by these grants should be designed to last two years, with costs not exceeding $275,000.

It is my hope that medical professionals will take this opportunity to address health disparities in their communities in a creative and innovative way. mHealth holds a growing potential to improve health conditions among those populations most strife with health disparities. Increasing patient adherence by using technology to foster patient-doctor communication will certainly prove effective in the very near future.

As a pre-medical student and a future doctor I’m well aware of the fact that it will be a number of years before I become a practicing physician. I’m also very well aware of the fact that the medical environment and community that I will be practicing in could be very much different than the medical environment of today.

That’s neither a good thing nor a bad thing, hopefully it’s good, but for now it’s just a fact. So I always do my best to keep an eye out for information that could help me understand the direction medicine is going so I can envision what medicine will eventually look like.

One thing I hear a lot about is this effort to hold doctors accountable and to empower patients to use data to select the most appropriate healthcare. I think the goal behind that mission is absolutely wonderful. Doctors are supposed to first and foremost help their patients, and patients deserve the opportunity to be able to learn and decide for themselves where they want to obtain their care.

The only concern I have though, is that the metrics and data being provided to patients to make their decision are not always truly indicative of good care. For example, one thing I’ve heard about is both paying and judging surgeons based on their rates of complications. Seems like a decently fair strategy. But what happens if you’re an amazing surgeon, but you decided you wanted to help a lower income population. Isn’t very much possible that the environment your patients are in after they leave the surgery could affect the degree to which they have complications? That doesn’t necessarily make you a worse doctor does it?

Just the other day I came across a phenomenal article about this subject from Lisa Rosenbaum MD, from the New Yorker titled “What Big Data Can’t Tell Us About Healthcare”.  In this article she talks about a recent release of Medicare payments that was made available to the public. In this release anyone, including patients, can look up the amount doctors are billing and how they rank amongst their peers.

The basic idea is that transparency can help patients make informed decisions.  And the implied message is that doctors who are billing higher are misusing the system and ripping you off.

“The hope is that members of the public will be empowered by their access to payments data, and will use this information to identify doctors who are behaving badly, helping to end fraud and profit-driven overuse.”

But that’s extremely missing. Just knowing how many Medicare specific treatments your doctor does , how much he or she bills for them, and what their total overall billing is does not provide nearly the whole picture. You don’t know what the doctor’s costs are; maybe the area they are in requires higher costs? You don’t know the exact breakdown of the doctors billing system within their practice. Often times a single doctor bills the entire practice’s procedures.

And there is an overall dilemma between doctor judgement and what’s deemed as necessary that  this also highlights. Is a test unnecessary just because it doesn’t return positive results?

How do we define quality care and how do we provide patients with a data set that is truly reflective of that? That’s still a challenge that is yet to be answered.

http://www.newyorker.com/online/blogs/currency/2014/04/the-medicare-data-dump-and-the-cost-of-care.html

During our final critique last night, many of the comments of our proposed app addressed concerns about the reliability of patients’ self-tracking information. In other words, will a patient honestly report that they have taken their medications and followed their exercise and diet plan for that day?  Most comments acknowledged that we could link our app to different programs such as a Fitbit, a Nike fuel band, and prescription refills to monitor whether a patient was actually fulfilling their treatment plan. These modifications would provide objective data that the patient is following through with their treatment plan.

source: medgadget.com

While these modifications would definitely streamline the process of providing correct information, I think they miss one of the most valuable aspects of self-tracking. Since I our app, the patient has to check off which aspects of their treatment plan they followed during the day, it automatically forces them to reflect on their day and their progress in achieving their goals. If the information automatically syncs to the app, it eliminates a crucial step in the goal setting process, which is reflecting on your current progress in achieving your goals.

source: newyearresolutions.org

The problem can be viewed from two different perspectives: the patient perspective and the physician perspective. From a physician’s perspective, it is extremely useful that the automatically recorded data would provide objective findings on a patient’s progress. A physician could see that a patient is only running once every two weeks from the information provided in a fit bit or other device. It reduces the need for the physician to rely on accurate self-reporting by their patients. From a patient’s perspective automatically reported data reduces time spent self-tracking, but it ultimately doesn’t make the patient more engaged in their treatment plan and illness.

If we move towards an app that relies less and less on patient self-tracking it also moves away from a collaborative physician-patient relationship. The goal of our app is to create a shared-decision making tool that can be used at the clinical encounter. We wanted to move away from the historical physician-patient relationship which is very unidirectional. In this model, the physician tells the patient their treatment plan, and the patient follows that treatment plan. The purpose of self-tracking is to have the patient track their health to make them more engaged and better able to manage their condition. If we remove the physical process of entering in information, we risk losing patient’s engagement and thus decrease a patient’s responsibility of their own health.