Dial M for medicine: The smartphone is revolutionizing the ways patients engage with doctors and manage their health

This article appeared in Genome in September 2016.

During her freshman year at Muhlenberg College in Allentown, Pennsylvania, Isabella San Miguel woke to pounding on her dorm-room door. She bolted upright in her bed and instantly felt the unmistakable dizziness of low blood sugar. Before she got up to answer the door, she reached for the juice box tucked into a pocket in her bedsheets. The sheets are made to hold TV controllers, but San Miguel uses them to stow a juice box and her iPhone, which pings when her blood sugar starts to drop. This time, she slept right through the pinging when her sugar fell to 80. When it fell to 65, pings went out to both San Miguel and her mother, who was fast asleep in San Juan, Puerto Rico.

“When my mom called me, I still didn’t wake up, so she called Campus Safety.” That’s because sleeping through hypoglycemia can be life-threatening. “They came over and knocked on my door,” recalls San Miguel, now a sophomore. “When I heard the knocking, I immediately knew that my blood sugar was low. I answered the door with the juice box in hand.” Once the officer confirmed that San Miguel was all right, he bid her good night, and she went back to bed.

San Miguel, diagnosed with type 1 diabetes when she was 4 years old, wears a continuous glucose monitor (CGM). The tiny needle of an electrode measures glucose levels in fluid just under her skin. The sensor sends readings to her iPhone and Apple Watch. “I can see my blood sugar as easily as flicking my wrist,” she says. “Knowing your blood sugar every five minutes takes so much off your shoulders. It makes decisions like insulin and carb-counting a lot easier. And now that it’s on my phone, and not a separate monitor, when I walk out the door, all I need is my phone, just like everybody else.”

Amazon and Uber have shown consumers that you can get whatever you want whenever you want it, and all you need is your phone. Health care, the industry that could make the greatest impact with this customer-centric model, has finally begun to adopt it. The same technology long used to buy instant movie tickets and make bank deposits now lets you share high-res photos of a skin rash with a dermatologist rather than wait months for an appointment. You can upload video of your baby’s inner ear for an immediate assessment from a doctor. Phone-connected EKGs allow cardiologists to monitor patients’ hearts remotely, not just during appointments. As healthcare apps take their place on home screens, alongside shopping, travel, and banking apps, patients are finding their place in the driver’s seat of their care.

DOCTOR ON DEMAND

The last place consumers feel that they’re in the driver’s seat is probably in the waiting room at a doctor’s office. Setting up and carrying out a traditional doctor’s appointment strikes a stark contrast to most any other transaction people make in their daily lives, whether it’s signing up for a yoga class, making a hair appointment, or ordering dinner. For starters, just booking the appointment usually requires a phone call. You wait to speak with someone; you wait weeks for the appointment; you wait in the waiting room; then you wait in the exam room. After all this waiting, you get a few minutes of face time with your doctor.

Telehealth visits — also known as virtual visits — are cutting wait times exponentially.

“When someone says, ‘I would like to talk to a doctor as soon as possible,’ our average turnaround time is eight and a half minutes,” says Henry DePhillips, the chief medical officer at Teladoc.

Teladoc — and competitors such as MDLive, American Well, Doctor on Demand, and NowClinic — offers virtual doctor visits at any time of day or night. These consults average about $49, according to data analysts at IHS Technology. Teladoc contracts its services out to employers who offer them as an employee benefit. Patients can use the app to request an immediate consult or an appointment on a specific date. They can simply speak to the doctor by phone, upload high-resolution photos of their ailment when appropriate, or schedule a face-to-face video consult.

Patti Broyles, a director of development for a nonprofit in Fort Worth, Texas, was visiting family in Chicago when she started to feel symptoms of her recurring bronchitis and sinus infection. “When I get a sinus infection, I know that it’ll become lodged in my chest, and unless I do something right away, I’m not going to be in good shape,” Broyles says.

She couldn’t afford to wait until she got back home to Texas to see a doctor. By that time, she’d have a full-blown sinus infection and would have to take time off from work. “I called Teladoc, left my number, and within 10 or 15 minutes, the doctor was on the line, responsive, asking me all the questions my primary care physician in Dallas would have asked,” she recalls. That afternoon, Broyles started the prescription that the Teladoc provider had sent to the nearby Walgreens. She never had to miss a day of work.

In 2015, a third of employers offered telehealth services to their employees. About 50 percent of those who weren’t offering the benefit plan to this year. Twenty-nine states and the District of Columbia require that private insurers cover telehealth to the same degree that they cover in-person visits. Some insurers voluntarily cover the service or plan to soon.

It’s no wonder employers and private insurers offer this benefit. While telehealth visits are still relatively new, early studies show that the platform cuts costs. In a study of Medicare beneficiaries with chronic disease — these are among the most expensive patients in the U.S. — those who incorporated telehealth into their care saw a cost reduction of 7 to 13 percent. That’s about $1,200 to $2,170 in savings a year. Patients of the Veterans Health Administration had 25 percent fewer days in a hospital bed and 19 percent fewer hospital admissions after they enrolled in a telehealth program.

Virtual visits might not be appropriate for every need, but they can address many of the issues that put people in emergency rooms, urgent care facilities, or on long waits for specialists. “For sinusitis, bronchitis, urinary tract infections, skin problems, pinkeye, this is totally appropriate,” says DePhillips. Virtual platforms offer psychiatry and counseling, too. If it turns out that a problem is too complex for a virtual visit, DePhillips says, Teladoc refers the patient to an in-person provider.

In fact, apps can order in-person providers, too. Heal, and other programs like it, allows you to request a house call. Just as with Uber, you can track the doctor’s progress toward your home through a map on your screen.

But can a FaceTime or Skype session with a doctor lead to the lifelong relationship some people cultivate with their family doc?

“There are already care models where you have a physical, in-person visit the first time, and then most of the subsequent visits are virtual,” says Eric Topol, a cardiologist and researcher at the Scripps Research Institute in La Jolla, California, and a member of Genome’s advisory board. Topol researches the ways genetics and digital technology can be used to make medicine more personalized.

“Virtual visits with your primary care doctor will one day be the norm,” he adds. “There will still be the trust and significant bond with the primary care doctor, but the physical visits are eventually going to be for serious matters like an important diagnosis or a sit-down for a critical discussion.”

Some hospitals use remote monitoring apps to interact with patients and track their recovery after discharge — a boon in an age when hospitals can be penalized for readmissions. Elsewhere, dissatisfied patients at Geisinger Health System in Danville, Pennsylvania, can register complaints and request refunds through a smartphone app.

While virtual doctor visits on the screen of a smartphone may seem futuristic, they’re starting to enjoy mainstream uptake. In fact, Broyles, who is 59 years old and has used the service twice, describes herself as “almost pathologically resistant” to new technology.

Video visits between primary care providers and their patients are expected to double over the next four years, from two million last year to more than five million by 2020, says a report compiled by IHS Technology. Total U.S. video visits, including primary care and specialty consults, are projected to reach 27 million a year by 2020.

SENSORS AND DEVICES

Sensors like San Miguel’s continuous glucose monitor will help doctors and their patients realize the full potential of virtual visits. “One of the best things that the glucose monitor has is a summary app,” San Miguel says. “It generates a code for the doctor’s office, and they can print out my blood sugar readings for up to six months.”

This can facilitate in-person doctor visits or allow the doctor to assess San Miguel without seeing her in the office at all. The summary app can also identify patterns. If San Miguel’s blood sugar plummets every day around 4:00 p.m., for example, the app will let her know so she can make appropriate adjustments to her diet, exercise, or medication.

“This is a great way for people with diabetes to get training wheels, by giving them feedback as to when and how glucose gets so out of whack,” Topol says.

Topol looks forward to a near future when sensors relevant to other conditions are as widespread as the continuous glucose monitor. He concedes that right now, the range of services doctors can provide based on a video visit, without the ability to do a physical exam, “is pretty narrow. But very quickly, people will be able to either have Amazon deliver, or go to their drugstore to pick up, the equipment that they need to generate the data that is critical to the [reason for the visit].”

Some of the equipment already exists. FDA-approved electrocardiogram (EKG) sensors allow you to take an EKG and share the results with your doctor. You can press your fingertips into electrodes on the back of your phone or use a special wristband on your Apple Watch. The electrodes cost less than $100 and may require a nominal monthly subscription fee of about $10 to get test results.

Doctors can implant defibrillators in their patients and monitor them wirelessly and remotely. A defibrillator detects an abnormal heart rhythm and delivers an electric shock to get the heartbeat back on track. The device doesn’t require remote monitoring by a physician, but studies show it makes a difference. When doctors studied more than 37,000 patients with defibrillators for three years, they found that patients whose devices allowed for remote monitoring were significantly less likely to be hospitalized or to die for any reason during the study period.

“Suddenly we’re getting this daily wealth of information from these devices, versus visits with patients four times a year,” says Leslie Saxon, a cardiologist and the executive director of the Center for Body Computing at the University of Southern California’s Keck School of Medicine. Saxon co-authored the study on remote heart monitoring. “I felt the promise of being able to take care of patients digitally by looking at data every day, getting earlier diagnoses, and being able to intervene earlier,” she says.

Parents can use their smartphone to get a fast, middle-of-the-night opinion on a child’s aching ear. Using an otoscope attachment that slides over an iPhone camera lens, parents can use the accompanying app to shoot a video of their child’s inner ear. They send the video to a physician on call and get an opinion — is it or isn’t it an ear infection? — for $10.

Aaron Robbin, a Chicago-based father of a 4- and a 2-year-old, says the $70 device has saved his family time and money. “Two-year-olds don’t necessarily communicate easily,” Robbin says. “Between teething and ear infections, you just never know what the problem is and what the response should be.” Ruling out an ear infection via smartphone, he says, can save a costly late-night visit to urgent care.

New portable ultrasound devices connect to smartphones, too. They won’t necessarily have patients performing ultrasounds on themselves at home. But they do have the capacity to increase access to high-quality care for people in remote areas.

“Everyone’s expected to have an internet-connected phone,” says Saxon. “So, if developing economies don’t have to build a huge infrastructure [to get health care] and they can take care of issues virtually, they can build a targeted infrastructure and address things like maternal fetal health.”

The ultrasound devices can also expand the scope of practice for physicians who don’t typically own standard ultrasound machines, while lowering costs and reducing unnecessary tests. Topol has used the handheld device in his exam room for more than five years. “I hardly ever have to send someone for a formal ultrasound, because I already see everything,” he says. “There are over 135 million ultrasound studies in the United States each year. If these were performed as part of the physical exam with handheld/smartphone ultrasound, there’s the potential of reducing 60 to 70 percent of the formal scans, which could translate to a savings of $100 billion per year in unnecessary studies.”

SELF-HELP BY SMARTPHONE

Ap stores offer many health-related apps that don’t necessarily incorporate or rely on communication with a healthcare provider. Physicians have begun to review these apps online to give potential users an idea of how well they work. Some reviews, both favorable and unfavorable, can be found at Ranked Health. Apps might help track and address blood pressure, medications, sleep, snoring, fertility, and symptoms of a number of other mental health conditions.

Mental health apps might have the potential to reach people that traditional health care does not, as the apps may allow users to take the first steps toward care with greater anonymity. For now, however, few apps seem to incorporate strategies that are backed up by scientific evidence. A review of more than 100 self-help apps for depression found that only 10 percent of them used proven methods. Still, some mental health apps get strong reviews from experts. PTSD Coach earns high marks from the Anxiety and Depression Association of America. The app teaches users about post-traumatic stress disorder (PTSD), helps them assess and manage symptoms, and points them to resources for professional help and peer support.

BETTER HEALTH CARE IN YOUR HANDS

Mobile health is still in its infancy. As the field matures, smartphones shouldn’t just bring the status quo to the comfort of consumers’ homes. They should bring something better. The current physical exam leaves much to be desired.

“The stethoscope is obsolete,” Topol says. “It’s an analog device with terrible inaccuracy and limitations.”

The limitations of the healthcare system and its technology extend far beyond the stethoscope to include inconsistent access and flawed screening tools. Smartphones and the digital technologies that they enable inject health care with a heavy dose of potential.

“With our ability to digitize a human being through smartphone apps, we’re going to know so much more about each individual, because we’ll have real-world, real-time streaming data, like blood pressure and glucose 24/7,” Topol says. “Ultimately, I expect there will be improved outcomes, because we’ll be capturing data that we could never capture before.”

Some people have already enjoyed the fruits of this round-the-clock, real-time data — in a juice box in the middle of the night.

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