With smartphones and wireless technologies becoming ubiquitous, mHealth
(mobile health; also known as “connected health”) is one of the hottest areas for healthcare tech innovation.
What will this mean for primary care? Well, if you’re a clinician and want to know what many thought leaders in mHealth think is important (and think of us), I highly recommend you read this essay by Robert McCray, the President and CEO of the Wireless-Life Sciences Alliance.
Here’s a summary of the key points as I understand them:
- The problems:
- An epidemic of obesity and chronic diseases, in large part due to people’s behavior choices and lifestyles.
- Individuals erroneously assuming that technology will save them from the consequences of their behavior.
- People have ceded responsibility for fixing their health to institutions paid by third parties.
- Physicians have focused on “transaction-based medicine” and have not focused enough on improving the health of patients through modifying harmful lifestyle choices.
- Physicians have focused more on defending their turf, autonomy, and income, than on the health of patients.
- Neither patient nor provider has responsibility for health outcomes.
- The solutions:
- People must “embrace the responsibility for their health and demand the tools to discharge it,” rather than assume someone else will take care of the problem.
- Citizens and consumers must set expectations for the institutions that deliver healthcare services.
- Physicians should “‘prescribe’ healthier living habits by directly addressing the harmful lifestyle choices that their patients present.”
- mHealth tools will provide access to “all the knowledge that is needed to reduce the need for healthcare and to select the best healthcare approach when it’s necessary.”
In summary, a major problem is that people are making crummy lifestyle choices, and physicians aren’t doing enough to help them with this. People need to take responsibility and armed with the tools of mHealth, need to start ensuring that they get help making healthier living choices.
Well, maybe this could work if we’re talking about a population of younger educated Americans. But what about the millions of older people now struggling with multiple chronic health problems? Don’t they need much more than healthier living habits and prevention? And how much responsibility can we expect them to take on?
When consumers need more than lifestyle changes
McCray makes some good points in his manifesto. However, his proposed solutions aren’t enough to handle the most pressing health policy priority of the next 30 years: effectively managing the primary care of the Medicare population.
In particular, how well would these ideas work for the many older adults currently suffering from multiple chronic illnesses?
Consider the patient scenario I described in my recent post on managing multiple recommendations: an older adult diagnosed with diabetes, high blood pressure, arthritis, and glaucoma, and experiencing falls, urinary frequency, anxiety, social isolation, and difficulty managing medications.
Let’s say this person is a 70 year old overweight woman, and let’s call her Janet Doe.
How well do McCray’s analysis and proposed solutions fit with what I know of patients like Janet Doe?
Well, it’s true that poor eating and exercise habits, and obesity, are strongly correlated with developing and exacerbating diabetes, high blood pressure, arthritis, urinary complaints, and cognitive impairment (which could be why Janet’s struggling with her meds).
So maybe she made poor lifestyle choices. Or maybe she made the best choices she could in her life circumstance. Who knows? Public health professionals know that people’s health is often strongly affected by factors that individuals have difficulty controlling (like fast food advertising, access to safe parks, etc).
Otherwise, I wouldn’t be surprised if she didn’t get the best comprehensive primary care (so hard to provide good primary care under conventional practice circumstances!) or good behavioral interventions. And yes, she probably was assuming that the system would take best care of her.
Let’s move on and now talk shop about mHealth helping her out. I have four particular comments in response to McCray’s article:
- Many patients need more from clinicians than the prescription of healthier living habits. A patient like Janet Doe needs high-quality outpatient medical care to manage her many medical problems. This should be grounded in a mutually respectful collaborative relationship with a clinician. Obviously we have a long way to go before clinicians routinely offer patients the engagement and patient-centeredness that everyone deserves. We do need patients and families to constructively demand more from their doctors and their healthcare. But let’s be clear about the outcome we need. It’s not doctors addressing harmful lifestyle choices. It’s doctors applying the full range of their medical expertise, in order to help patients and families achieve the best health outcomes possible given the medical circumstances and the patient’s preferences.
- Many patients don’t want to be in charge or responsible. Hard for us educated control freaks to always appreciate, but in my experience true. I find patients and families especially prone to become overwhelmed once there are more than 1-2 chronic diseases to deal with. And of course, less educated patients generally struggle more than educated ones.
- Many Medicare patients will develop cognitive impairment. Presumably in McCray’s vision, responsibility then devolves to the spouse or next of kin, as it does now for financial affairs. But these family caregivers are already struggling to manage medical responsibilities. We should only lay more responsibility upon them if we really are able to offer tools and resources that will make this added work manageable.
- Medically complex patients absolutely need a physician’s expertise to synthesize the ongoing care of multiple chronic conditions. You can call it a quarterback, a navigator, an expert outpatient consultant (my current practice), or just a plain old-fashioned good PCP. Whatever you call it, it takes a live person with physician-level expertise. Patients need and want to talk to someone who can help them sort through the complexity and choose among the options. New technologies can offer much needed support to everyone involved. But if we want to improve the care of older people, we need to support that patient-clinician partnership, rather than imply that it can be replaced.
What we really need from mHealth, to care for the health of aging adults
My short(ish) answer to this question is that we need tools that 1) allow clinicians to do what they need to do, faster and more efficiently; 2) allow patients and families to do all the extensive self-management that they have to take on, and 3) facilitate effective collaboration, communication, and shared decision-making between clinicians, patients, and care circle.
Here’s a wish list with some specifics that could help me with my daily clinical practice:
- Tools to manage the multiple recommendations we generate when we see patients like Janet Doe.
- Tools to help clinicians and families manage medications, especially when multiple providers are involved.
- Tools to help patients and families gather the daily data we all need to manage their chronic problems, i.e. tools that collect the symptom information as easily as possible, and then make this data digestible and actionable for patient, caregiver, and clinician.
- Tools to help multiple involved parties communicate. Older patients have family caregivers, private caregivers, home health agencies, hospitals, facility staff, and other clinical specialists involved. Need help keeping everyone in the loop and coordinated.
- Decision-support tools. Do you want us to discuss the risks and benefits of a certain medication or procedure? Make that data easier for the clinician to access quickly. Make it easy for families to find suitable decision guides for common medical decisions.
- Better personal health records. Patients should be able to easily access their medical information. They need meaningful summaries. They need access to their labs and other diagnostic data. They need to be able to easily share this with the clinicians of their choosing, so that they can help coordinate their care, get the right care in an emergency, or easily ask for a second opinion.
I could go on, but I’ll stop there for now. Clinicians, what’s would be on your own mHealth wish list?
To Mr. McCray and his colleagues, I applaud their much needed efforts to change healthcare, and I do think mHealth technologies have wonderful potential to improve the health of the elders and families I work with. The questions to keep discussing, of course, are how to apply these technologies, how to redefine the roles of patients and families, and how to enable clinicians to do their best work in partnership with patients.
In a nutshell
An approach relying on consumer-directed health and mHealth-powered lifestyle management could work for the educated and relatively healthy American. But many seniors with multiple medical problems will not be able to take on primary responsibility for their health outcomes.
Most older adults need more than prevention and healthier living habits. When people have multiple chronic illnesses, they have substantial ongoing primary care medical needs. These older adults will need physicians to help them synthesize the care of multiple conditions, and to navigate complex medical decisions. mHealth can’t replace this partnership, but can certainly support it, by creating tools that facilitate effective collaboration and communication between clinician, patient, and caregivers.
