'The Future of Medicine': The Emergency Room And Mobile Health

Neal Sikka I studied biochemistry in college and then went to medical school at Washington University in St. Louis. While I was always interested in computers, my interest in health technology began when I helped implement the first Emergency Department electronic medical records system at George Washington University Hospital in Washington, D.C. In addition, we have had a longstanding maritime telemedicine program at GW, and I am interested in how we can use technology to deliver better care.

David Barash I am an emergency physician, and have been practicing for almost 26 years. I am drawn to the acuity needed in the field, as well as the variety of patients. I love the teamwork, and intense interactions with staff, patients, and their families. You need to be an effective and rapid communicator. You also need to be very innovative and creative, and able to adapt to new situations.

Very often, you have to react and make decisions on the basis of limited information. I got into the mobile health field because I believe it is the future of medicine. I helped develop an iPhone app on cardiopulmonary resuscitation (CPR) that allows more effective chest compressions, and am currently very interested in how I can help GE Healthcare apply mobile health technology from the clinical point of view.

Neal Sikka I consider mobile health to include mobility of the patient and of the provider, and being able to be more connected. Take, for example, the way you are connected to your physician. In general, you see him or her once a year for your physical, and twice a year if you get sick. Mobile health allows you to connect to your doctor when you are healthy, and keep track of your health when you are well.

Also, instead of being tied down to a structure or device in a hospital, patients can now be mobile within the hospital. I believe that anything that gives the physician freedom to provide better care is also mobile health. We want to keep the definition broad, and not constrict our thinking to mobile apps alone.

David Barash In the broadest sense, mobile healthcare is anything that can be moved with the patient or with the caregiver. We've had for a very long time some portable machines, such as portable x-ray devices; but mobile technologies have now morphed into mobile phones, tablets, and leveraging the cloud, so what we are really talking about are phones and devices.

Neal Sikka There is no simple answer, and we are really at the very early stages in this field. But I believe that there can be quite an impact. For example, remote monitoring devices at home may reduce emergency room visits and hospitalization for patients with chronic diseases.

Simple interventions, like reminding patients of their appointments through short message service (SMS, or texts) can reduce missed appointments. The U.S. Department of Veterans Affairs (VA) has conducted large studies of continuous home monitoring and coordinating care with a remote nurse to help keep patients from being hospitalized.1 This saves patients a visit to the clinic, and prevents unnecessary admission to the hospital. At the systems level in healthcare, this can reduce cost.

There are many different aspects to mobile health—data collection, transmission, analysis, and virtual visits—and each aspect can either save money or increase revenue. In clinical trials, the cell-phone based WellDoc diabetes management system tested the effect of mobile device feedback to patients in reducing the blood diabetic marker hemoglobin A1c. The study found that by changing patient behavior using the mobile diabetes management system, an outcome similar to treatment with a diabetes drug could be obtained.2 The crux of mobile health is behavioral change.

David Barash Hospitals, almost by definition, have a highly mobile workforce, and so it's really important to leverage mobile technologies. Nowadays, patients are also moving around with their caretakers. This has created some challenges, but has also enabled the mobility of patients and providers, and will ultimately improve outcomes. In particular, enabling patients to be mobile early will improve patient outcomes.

Easier access to data, will also allow physicians to react more quickly to complex patients. We can now give providers the right data at the right time, on the right device, to provide the right patient care. We can fundamentally change the way hospitals operate. Improved productivity due to tools on these devices will allow clinicians to communicate with other clinicians better, through real-time exchange.

Neal Sikka There are three challenges to healthcare: access, quality of care, and cost-effective care. Mobile technologies—not isolated, but as part of the system—can potentially impact all three of these areas.

Access can be increased by being connected in real time, connected asynchronously, and being able to access records and work tools on the go.

Quality can be improved with more access and better tracking of personal data through wireless monitoring during care. Cost is currently incurred when a patient meets a provider in person. By collecting and tracking patient data and intervening with virtual visits, we have a new model, in which cost is incurred according to medical outcome rather than physician visits.

To give an example, in our hospital, ambulances transmit electrocardiograms (EKG) to the emergency room (ER) before arriving at the hospital. This means the doctor has more access (sees the EKG before the patient arrives), can provide better care (can prepare equipment in advance) and can be more cost effective.

David Barash One of the major benefits is that you can compare data in real-time. We work with AirStrip Technologies, a San Antonio, TX company, and if I am working with a cardiologist on a particular patient, I can get cardiac data in near real time. If a patient develops chest pain in an ambulance, the paramedics can determine whether the patient is having a heart attack, and I can look at an ECG with a cardiologist before the patient arrives at the hospital. This improves what is known as “door-to-balloon” time—in other words, the patient can go directly to the catheterization laboratory or cath lab rather than the ER, which cuts out 30-90 minutes from the process.

The door-to-balloon time is a big issue for emergency physicians and cardiologists. Another major benefit is with physician communication, and sharing information. I think that there is great opportunity, particularly with tablets, to work with patients—showing them information by their bedside, for example. I can also enter patient information into our database while talking to the patient at the bedside, eliminating time and errors involved in moving to another location to enter the information.

Neal Sikka The biggest difficulty right now is how to assess the impact of mobile technologies on security and privacy. Also, there is the potential of many applications being developed that do not affect or improve patient outcomes. Are we going to spend more money without knowing outcomes? Management of mobile devices and privacy issues, whether the devices are physician-owned or enterprise-owned, is key. It is really early in the process however.

David Barash One of the biggest challenges is the vast amount of data that physicians today are asked to manage. We are trying to figure out where all these streams of data are coming from, and need to determine how to make these usable for physicians, as well as the distribution of data (to whom and when). Taking the data, making sense of it, understanding its importance, and who it needs to go to—these are all important. Visualization is also a big piece of the puzzle and a potential stumbling block, but the latest mHealth applications are specifically designed for smartphone and tablet screens, functionality and mobile environments, which is certainly advantageous.

Neal Sikka I use my smartphone for reference applications in my clinical practice. In the ER, we use portable ultrasound. In cardiology, physicians use hypertension and diabetes remote-monitoring apps. One of my colleagues in the GW School of Public Health developed a program for SMS messaging to help people quit smoking. We will be using tablets for our telemedicine programs.

On the other hand, not all our physicians carry around iPads to provide care or show patients results. Patient privacy concerns, bandwidth limitations, and the current emphasis on meaningful use are all limiting both administrative and technical resources from implementing mobile health applications. As there is more clarity in these areas, I think we will see more direction and adoption in hospitals.

David Barash Almost all of us have a mobile device—in excess of 90% of physicians have some kind of device. In my practice, every one of my colleagues has one. Some use mobile devices to access electronic records and information (such as drug and disease info), and some use applications, medical calculator apps, and so on. It is growing.

The use of these devices in the emergency room depends on whether mobile devices are tied or not to the hospital system. The fact that some institutions do not currently use mobile solutions is probably due more to the pace of technological adoption and evolution in those institutions rather than other factors, such as security concerns.

Neal Sikka There has not been much impact yet. Electronic health records, however, which can be considered part of health information technology and by some extension, mobile health, have made information much more accessible, and have improved some workflows, but made others more difficult. We are constantly trying to leverage our technologies to improve workflows to maximize efficiency.

David Barash It has definitely improved efficiency. I can use a tablet at the patient's bedside and enter information immediately into patient records in real time, saving time, and reducing errors. Also, if I have a tablet with me, my workflow is improved. If it is with me at all times, I can converse electronically or by phone with other healthcare providers, and can access and impact data.

Neal Sikka People who have physician friends often send them wound photos by mobile phone to ask their medical opinion. We looked at whether cell phone images of acute wounds could be used to accurately determine whether an individual needs stitches. We compared the accuracy of diagnosis from an in-person visit versus mobile phone diagnosis of real patients, and got really encouraging results.

The study will be published later this year. This could be a viable approach to some types of diagnosis in the future. The upshot is that you may be able to help people who are unsure about whether they need to seek care, and unnecessary visits to the ER can be prevented.

Neal Sikka There have been all kinds of stories. For example, during the Haiti earthquake, someone used an app to splint a broken bone. There have been many individuals who have lost weight by using tracking apps on devices. Mobile applications that have a social component can also be very influential on an individual's behavior.

David Barash I see patients using tablets to access information on the web and communicate with physicians through portals. They also measure their own data, such as blood pressure and heart rate. We are just now scratching the surface in this field, but there is no question that patients do access information.

To give a personal anecdote, I was recently working with a patient who had a tick bite, and who wanted to know whether the bite was from a deer tick or a dog tick. Using my mobile device, I was able to show them the difference between deer ticks and dog ticks, that the bite was from a deer tick, and that I therefore needed to treat the patient to help prevent Lyme Disease.

Neal Sikka That depends on the patient, and whether they feel that technology puts a barrier between them and their physician. But in general, I think, mobile technologies bring patients closer to their physician: Through technology they can cultivate that relationship, and break down some barriers. As long as there is some way to filter all the information that comes in, this technology ultimately improves doctor-patient communication.

David Barash The best effect can be seen in the primary care world. Traditionally, a patient calls the physician, who calls the patient back, and this can take from an hour to several days. If you have the ability to email the physician and ask a question, it may take less time to receive a response than by phone call, and will allow you to get information that you might otherwise not receive.

This may bring you closer to the physician, enhancing the patient-doctor relationship. There is an opportunity to connect a little more. For example, I can communicate with patients via e-mail and respond to questions within 12 hours. We don't see as much use for this in emergency as in primary care, as we don't have a specific patient group, but use will increase fairly soon.

Neal Sikka Increased knowledge and information definitely has an impact on patients, although this is not necessarily related to mobile health alone. A few years ago, we conducted a study in which we asked patients whether or not they had accessed online information before coming to the hospital, and many said that the online information had made them change their minds about going to the hospital.3 So there is a definite impact on the patient.

David Barash mHealth will probably expand the use of wireless technology, which will impact self-diagnosis and treatment, as one doesn't have to be at a computer. I think self-diagnosis and self-treatment can be good. The trend is moving away from patients having to ask a doctor, and patients can take more ownership of their care, using their devices to track and get information more quickly.

Neal Sikka The next step from a GW perspective is outcomes-based research. We need to look at individual patient populations and determine whether the mHealth intervention leads to an improved and measurable outcome over time, and whether this health benefit is sustainable.

David Barash Thinking about this as an emergency physician, it is critical to allow us to monitor patients, or allow patients to monitor themselves continuously or near continuously. We need to move more towards patients being as mobile as possible. Medical body area networks (MBANs) are getting a lot of attention, and will revolutionize the way care is being delivered. They mean that the patient is not tethered to one place. The recent FCC ruling on MBANs will revolutionize the field.

Neal Sikka In the future we will design different workflows, and share more information with patients. I think we are already seeing mobile health and telemedicine improving healthcare in developing nations. As we become more connected, and as costs drop, we will see a lot more virtual visits as well as patients self-tracking of health. This data will be more available to physicians—hopefully moving us towards preventative and personalized medicine. I am looking forward to seeing who wins the Qualcomm Tricorder X prize.

David Barash Thirty years ago, in 1982, magnetic resonance (MR) was just being introduced. Cell phone technology, Wi-Fi, the Internet, high definition imaging, all did not exist yet. EKG carts, ultrasound and portable X-ray machines were the most mobile technology around. If you think about how fast things move, 30 years from now, healthcare will be delocated. It may not be as hospital based. Care will be delivered where the patient is, where the provider is. Also, the patient will have an extraordinary amount of control.

Without question, all transmission of data will be wireless, like MBANs. It is not inconceivable that healthcare will look like that in Star Trek! We need to be more connected to patients, and there is no question that healthcare will become more and more mobile. Given technological acceleration, the innovations you are about to see are amazing.