The Affordable Care Act may have gotten all the attention, but American medicine will be transformed even more profoundly by forces that neither the government, insurance companies, nor even doctors themselves can fully tame. It’s already happening, and three trends provide a preview of the shape of things to come.
BY WILLIAM HANSON
As with many healthy industries, medicine is constantly in ferment. Expansive forces generate new treatments and tools, as well as the specialists and specialties that deliver them. Then, limitations focus the application of the resulting new disciplines and cull out older ones that are no longer competitive. Like banking, manufacturing, and publishing, medicine is finally automating—albeit later. The relationship between the provider of the service and the consumer will be radically remade in the process. The consumer will have much more in the way of choice, autonomy, and leverage in the consumption of medical care, and the industry will become much more nimble as a result. Here is a glimpse at some of the solutions that are evolving in response to medicine’s flaws, the threats they represent to the complacent, and the promise they may provide for patients in the future.
The App Store Will See You Now
In one of the best episodes of the iconic science fiction series Star Trek, the ship’s doctor, nicknamed “Bones,” is called upon to examine a sick man on the outpost. He concludes, “Heartbeat is all wrong … temperature is … [he pauses], Jim, this man is a Klingon.” Dr. McCoy reaches this conclusion after examining the patient with his portable, universal diagnostic device, the tricorder.
While the tricorder was a figment of series creator Gene Roddenberry’s imagination in the 1960s, and today’s doctors still carry stethoscopes, ophthalmoscopes, and goniometers, we are getting closer to having an all-in-one portable diagnostic tool. This gadget is today’s cell phone. Many of the features that Star Trek’s writers attributed to Dr. McCoy’s utility tool are now emerging from mobile device app stores.
The smart phone itself can already be used as a stethoscope. Its microphone can be placed against the chest or abdominal wall to pick up sounds emanating from deep within the body. The application has programmed “wizards” that can be used by the novice to diagnose different sounds based on the location, audio characteristics, and type of sound. The program uses sound filtering and noise canceling features that amplify distant heart sounds. Previously these special sound-processing features were available only on expensive, high-end stethoscopes, but they’re built in to this inexpensive smart-phone application.
I recently downloaded Stethoscope Expert (a product of Current Clinical Strategies), one of several stethoscope apps from the medical section of the Apple store. It’s advertised as a way to employ one’s iPhone as an electronic stethoscope. In fact, there are many uses for the application—it comes equipped with an acoustic library of normal and abnormal heart, lung, and bowel sounds. When the user selects a given example, like the cardiac “quadruple gallop,” the phone cues up a movie (using QuickTime, Apple’s proprietary media player) that shows an acoustic trace of the sound and plays the accompanying audio. The term quadruple gallop describes a cardiac rhythm in which there are four, rather than the usual two, lub-dub sounds with each heartbeat. It is reminiscent of the hoofbeats of a horse at full tilt and suggests that the patient has severe heart failure. Whereas medical students, nurses, or paramedical trainees might have the opportunity to hear this sound in a real patient only once or twice during the course of their education, they can listen to the app’s example over and over until they’ve got it down pat.
The Stethoscope Expert library contains a suite of more than 60 different murmurs, rubs, gallops, clicks, and rumbles characteristic of different heart problems. A collection of lung and bowel sounds provides brief descriptions, phonocardiograms and audiograms of each. There are old favorites like pulmonary “whispered pectoriloquy” and “egophony,” and bowel “borborygmi,” “tinkles,” and “rushes.” There’s even a spooky recording of the “death rattle” described so often in old books—those written back in the day when ordinary people died ordinary deaths—at home. (The mind reels thinking about the technique for recording the rattle.) Used purely for its acoustic medical library function, this app has merit; but there’s much, much more!
An additional, extremely novel feature is the ability to record a patient’s heartbeat or lung sounds “for the record,” for comparison over time—even for analysis by someone else or by some futuristic computer with heartbeat recognition software. This opens up a world of interesting and previously unimaginable possibilities. A patient’s heart, lung, and bowel sounds could, for example, easily be recorded into a medical record with each physical examination. A primary care physician might record a worrisome exam and send it in an email to a consulting cardiologist.
The app’s designers may have anticipated that this kind of software might not win immediate acceptance by the brotherhood of medicine. Perhaps they hedged their bets by putting in a few additional features to win over nonmedical app shoppers who weren’t sufficiently enticed by the ability to play doctor with their iPhone on themselves or, perhaps more enticingly, on others. This iPhone app can actually “listen through walls!” What teenage boy could pass this up?
I tried this application on myself. When I used the phone’s speaker to project the sound, all I got was a screeching wail of feedback. But when I used ear buds, as the company recommends, I could actually hear lung sounds quite well, as well as the rumblings of my stomach as it churned away on my lunch. It was harder to hear heart sounds, but the company also sells a stethoscope attachment that can be plugged into the bottom of the iPhone and that’s better suited to cardiac examination.
In its current form, the stethoscope app is not really suitable for true medical use, but it won’t be long before we’ll have a version that would work just as well as or better than today’s traditional medical instruments. Considering the capabilities of sophisticated music-recognition apps like Shazam and Soundhound that can identify the singer, title, and composer of most music after a sample of only a few bars, one can readily envision something comparable for medical care.
The Stethoscope Expert isn’t the only smart-phone app designed to duplicate or demystify the magical things that only doctors were privy to back in the day. MIT researchers have designed NETRA, the Near Eye Tool for Refractive Assessment, to reproduce the techniques ophthalmologists and optometrists use to determine the prescription that a patient needs. With a specially designed mobile phone add-on piece, a non-specialist can determine how much refraction is needed to correct the vision of a near- or farsighted individual.
The patient looks through a lens at the phone’s screen and uses the phone’s controls to move parallel red and green lines closer and closer until they overlap. Depending on the degree of curvature of the eye lens, the overlap point will vary among individuals. The same process is repeated eight times, as the lines are rotated sequentially through 360 degrees to form a complete representation of the patient’s lens. Once the measurements are complete, special software calculates the prescription necessary to correct vision in that eye. The same process is performed for the other eye, and, with that data, a pair of corrective lenses can be made.
A UCLA professor, Aydogan Ozcan, and his group have developed a lens-free microscope weighing less than two ounces and designed to attach to most camera-based cell phones. Unlike traditional lens-based microscopes, the images in these inexpensive devices (less than $10) are captured using a process known as diffraction, which permits the reconstruction of an image from the shadows that it casts. A light-emitting diode shines through a blood or saliva specimen, and because the cellular elements in the sample are semi-transparent, both the cells and their subcellular elements cast shadows. The shadows are reconstructed into holographic images of the cells, which can then be transmitted from the field to a pathologist in some remote location, usually a hospital laboratory, for analysis.
This technology will soon be deployed in Africa, where cell phones are plentiful but pathologists are sparse. Samples, such as blood smears, can be quickly loaded onto single-use chips that slide into the microscope; and because of the large aperture of the sensor array, no special alignment or cleaning techniques are necessary—which makes this technology ideal for field use by relatively untrained workers.
Malaria is an example of a disease widely prevalent in Africa for which this technique is particularly suitable. A drop of blood can be applied to this “lab on a chip,” and the malarial parasites are easily identifiable.
While the typical telemedical analysis is done by an expert who analyzes an image sent using text messaging or email, Ozcan’s group has also developed an algorithm for local use. This is essentially an app that identifies and counts red cells, white cells, and microparticles like bacteria or parasites, permitting instantaneous on-site reports.
It is easy to imagine that technologies being developed for impoverished areas might eventually come to be used in medically well-served countries. The technology will improve, the cost will decrease, and the old methods will eventually be displaced.
Fujitsu has developed communication standards for medical devices and cell phones. The Fujistu phone uses the Bluetooth wireless protocol to gather information from similarly equipped machines that measure blood pressure, heart rate, blood sugar, and weight. While these phones are intended to store and forward the data to doctors at remote locations, the next wave of apps will allow a patient to record, interpret, and analyze his own data. We’re likely to see much more in the way of applications that allow each of us as patients to have more control over the acquisition of useful data for preventative and chronic health care.
As of this writing, there are already more than 6,000 medical or health applications in Apple’s App Store, and the numbers increase every day. Many of these apps are focused on the consumer rather than the provider. There are apps to track caloric intake, exercise, and weight. This might reduce the necessity for weight-loss programs or change how we approach health education. There are specific applications allowing diabetics to follow the levels of a diabetic marker called hemoglobin A1c in their blood. These apps can track the individual patient over time, as well as the individual patient compared to others with the same disease in the same geographic area.
Cell phone medical tools are new, and the ways in which they’ll be used in medicine is evolving all the time. To be sure, innovative physicians are already using smart phones for expert advice and for applications that facilitate charting and prescribing. But it’s clear that some of the most innovative mobile tools will come from consumer-oriented products, or from tools originally designed as inexpensive alternatives to traditional devices.
Medical students were not traditionally high-tech oriented, but they now live at the cutting edge of technology. They are extremely savvy about new paradigms, transitioning smoothly from telephone to text to social networks for different types of communications, while their medical teachers are often much less comfortable with the era of electronic communications. Today’s students will begin their careers just as electronic health records become prevalent. And they’ll help to define the best ways to use these new tools that will dramatically alter the delivery and consumption of health care, right before our eyes.
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FEATURE: The Other Health Care Revolutions By William Hanson
Illustration by Mark Allen Miller
©2011 The Pennsylvania Gazette