Last week I attended a seminar on
mHealth sponsored by the Technology Association of Georgia (TAG). The presenter was Arthur Lane, Director of Mobile Health Solutions at Verizon
Wireless. He gave a nice presentation
and video of a system Verizon is designing to improve care of congestive heart
failure (CHF) patients after hospital discharge. CHF patients are treated effectively in the
hospital setting with closely monitored vital signs and carefully administered
medications / diet. The problem is that
once the patient goes home it is difficult to maintain the same level of
monitoring and precision of the medication / diet regimen. As a result re-admission rates for CHF are
high, adding to the cost of care.
The Verizon system claims to correct this problem with smart phone
technology. The video showed a smart
phone reminding a CHF patient to weigh himself before bed. He has gained ½ pound since the morning. When he wakes up the next morning the phone
again reminds him to weigh himself. He
has gained another pound. Weight gain
day-to-day is an indication that CHF is getting worse. The phone sends the weight data to a server,
which in turn notifies a provider to call the patient and somehow prevent him
from getting worse and showing up in the ER.
It was never clear to me how the provider was going to fix worsening CHF
over the phone.
After Mr. Lane completed his presentation he joined 3 other panelists
for a lively discussion moderated by a local physician whom I know. Some of these panelists described their
devotion to mHealth with near breathless excitement. The physician moderator posed the
ever-present question to the panel: “How
do we get doctors interested in this system (and mHealth overall)?” The answers ranged from good – “Give doctors
a product that is cost-effective” – to the ridiculous – “Align incentives by
making physicians join ACOs.” The
silliest thought of the night was the suggestion from one panelist that health
care is no different from banking. I left
the meeting with some concerns about who would pay for the Verizon system but
decided to hold my reaction until I did a literature review. After all, I am no cardiologist and have not
treated a patient for CHF since med school.
My review did not yield good news for Verizon or mHealth.
Turns out physicians have been working on home monitoring for CHF
patients for years. Unfortunately their
studies to not support remote home monitoring for CHF to reduce hospital
admissions. A study from Yale Medical School
published in the New England Journal of Medicine in 2011 randomized over 1600
CHF patients to either a control group or a remote monitoring group for
outpatient care following admission for CHF.
There were no differences in readmission rates for CHF or for any other
cause over the 6-month study. Several
other studies, including comprehensive reviews of existing literature, reach
similar conclusions.
So what would a more realistic mHealth video look like?
Our CHF patient is discharged from the hospital all tuned up with
appropriate medications, diet and smart phone remote monitoring using a CHF app. The monitoring app works well at first,
feeding him periodic words of encouragement and reminders to take his meds,
record his vital signs, weigh himself, etc.
After several days of his phone going off constantly with all the
reminders, alert fatigue sets in. After
ignoring the alarms for a few days he gets fed up and shuts the CHF application
off. The monitoring network detects the data
interruption, and a provider calls the patient.
At first the contact with a real human helps, but after several calls alert
fatigue strikes again. Our patient
recognizes the caller ID and stops answering.
In the meantime he tires of his medication regimen and diet
restrictions and succumbs to the urge to scarf down some pizza and beer with
some potato chips for dessert. His smart
phone isn’t smart enough to change his behavior. The salt and fluid load makes his heart
failure worse. In the middle of the night
he wakes up short of breath and calls 911.
Back to the hospital he goes.
The mHealth community is so enamored with their toys they can’t see
what is right in front of them:
1. Peer-reviewed medical literature does not
support the use of home monitoring for CHF patients. Period. LTE smart phones and glitzy medical apps do
nothing to change that.
2. Without
supporting literature no one is going to pay for remote monitoring.
Who is going to cough up the dough for all those smart phones, Bluetooth connected home monitoring devices, remote servers, and the army of providers that will be required to manage the terabytes of data that such a monitoring network would generate? Neither ACOs nor any other ill-conceived “alignment of incentives” for physicians solve this issue.
Who is going to cough up the dough for all those smart phones, Bluetooth connected home monitoring devices, remote servers, and the army of providers that will be required to manage the terabytes of data that such a monitoring network would generate? Neither ACOs nor any other ill-conceived “alignment of incentives” for physicians solve this issue.
3. The
mHealth folks fail to recognize that monitoring is not the endpoint. The endpoint is changing patient behavior. A
smart phone constantly shrieking warnings and reminders is rendered useless by
alert fatigue. Patient behavior is a
very tough nut to crack. The Verizon
video ends with a nurse talking to the monitored patient about his weight
gain. But that is NOT the end. It is just the beginning. No one knows what that nurse is supposed to
say to change the patient’s behavior over the phone.
4. Like
many mHealth ideas this system creates unrecognized changes to the standard of
care and thus changes medical liability.
What if our CHF patient who stops listening to alerts and stops
answering the phone dies while he is in the monitoring program? Who is liable?
So it’s the same thing all over
again with health IT. No proof of
effectiveness. No way to pay for it. No understanding of the medical challenges
involved. Unrecognized changes in
standard of care and liability. Health
care is not the same as banking.
Duh.
Verizon has no business getting
into health care beyond the LTE connection itself. They are going to lose their shirt investing
in a treatment the literature says doesn’t work. Perhaps unwittingly, the physician moderator, Dr.
James Morrow, said it best when he asked the panel, “Where is the app that
slaps my hand when I reach for the bag of Oreo cookies?”
Don’t get me wrong, folks. Our practice has enjoyed great success with
EMR in over the past 7+ years. Our
experience just scratches the surface of the awesome potential of health IT. I want you to succeed. But the health IT industry is headed in a
direction that will guarantee failure.
To succeed you must stop chasing pipe dreams and focus on the one goal
that must be met before anything else – HIEs, mHealth or anything else – can
succeed:
Find
a reliable way for doctors to succeed with EMR in the office setting. Upgrade EMRs to reflect some understanding of
the practice of medicine. Design patient
portals that actually work. Demonstrate
that EMRs are effective at improving care.
Design a business model that shows the path to a return on investment.
Until that goal is met, nothing
else matters.
