The trouble with apps that send data to docs

The Science section in the NYT has a special section on the “Digital Doctor” this week. The lead article, “Redefining Medicine with Apps and iPads,” showcases UCSF resident Alvin Rajkomar, who is — gasp — using MedCalc on his iPhone, to help him manage hospitalized patients.

This Exhibit A of new digital doctoring made me laugh out loud. You see, when I was a third-year medical student over a decade ago, I and many other med students and residents were using a similar program. We had hot new devices called PDA (personal digital assistants), and had replaced the usual pocket references with digital equivalents. As a matter of fact, I recall using something called MedCalc and it came in handy throughout residency, although once the rubber hit the road in internship, I switched back to pocket books for some references. (You can’t quickly skim lots of text onscreen the way you can skim pages of small text, and to this day, the one reference I always carry in my pocket when doctoring is my Tarascon Pocket Pharmacopoeia.)

A better glimpse into the future of smartphone-leveraged healthcare is in “Apps That Can Alert the Doctor When Trouble Looms,” which highlights an area that truly is new, exciting, and also slightly scary in the expanding world of digital doctoring.

To summarize, companies are developing apps that monitor patient behavior, and then send the data to health providers. The apps described use GPS monitoring and accelerometers to track patient motion. The idea is that a significant change in motion pattern could be signaling an important change in health status. Presumably at this point some kind of signal would be fired off to a doctor.

Here’s how they say it might be used for patients who have chronic illness and involved caregivers (i.e. my patients):

“Dr. Matthew Gymer, the director of innovation at Novant, said he wanted
to see how well the technology performed in alerting caregivers to
potential behavior changes in thousands of patients with different
conditions, including diabetes, chronic pain and heart disease.”

Ok, let’s talk about this. For now, we’ll set aside issues of patient privacy (some call this Big Brother but I expect most patients won’t mind) and properly calibrating the devices so that their alerts have good positive predictive value.

My main concern: are providers are ready and willing to be receiving this data?

Interestingly enough, some of the comments echo this line of concern, with one commenter (Atlanta mortgage broker) noting:

“These days, you can go repeatedly to your primary care and specialists
BEGGING for help, stating any dangerous mental state imaginable and
dangerous health issues such as uncontrolled diabetes and hypertension –
and they don’t even call you back or give you a decent appointment
date…”

On the provider side, AKS says:

“You want to know the first thing i thought about as a doctor? Picturing
me getting sued by a patient or their family and the lawyer saying: this
app shows that you received this information, yet there is no record
that you acted on it. i’m literally supposed to act on it, pull the chart, and then note what the
app said and what i did, and why i did it, and why i didnt do something
else. tort reform before i use this app.”

I think both commenters are highlighting the likely trouble with apps that send data to docs:

• Is there infrastructure to facilitate medical intervention, i.e. at the minimum available appointment to be seen?
• Doctors are already complaining of information overload and not having enough time to address patients’ needs, especially in the outpatient setting. Front-line providers are experiencing 60% burnout. Is this going to make their professional lives better or worse?

Last but not least, I have to say that caregivers I’ve worked with often have little difficulty noticing that something is wrong with their loved one. It’s after they notice that the problems start:

• They don’t know what to do or who to call, or even that they should call sooner rather than later (hence my search for delirium educational materials);
• They are unable to promptly access by phone a provider who has decent information about the patient;
• No appointments are available in the near future.

I do heartily agree with one  researcher’s point that relying on patient interviews to collect data is incredibly inefficient, so I’m interested in the promise of apps for this purpose.

But if the apps come before providers are ready and willing to get the data, we may very well see the current exodus from primary care get worse.