The Naivete of mHealth

Dr. Michael Koriwchak, www.wiredemrdoctor.com

I attended a seminar on mHealth sponsored by the Technology Association of Georgia (TAG). The presenter was Arthur Lane, Director of Mobile Health Solutions at Verizon Wireless. He gave a nice presentation and video of a system Verizon is designing to improve care of congestive heart failure (CHF) patients after hospital discharge. CHF patients are treated effectively in the hospital setting with closely monitored vital signs and carefully administered medications / diet. The problem is that once the patient goes home it is difficult to maintain the same level of monitoring and precision of the medication / diet regimen. As a result re-admission rates for CHF are high, adding to the cost of care.

The Verizon system claims to correct this problem with smart phone technology. The video showed a smart phone reminding a CHF patient to weigh himself before bed. He has gained ½ pound since the morning. When he wakes up the next morning the phone again reminds him to weigh himself. He has gained another pound. Weight gain day-to-day is an indication that CHF is getting worse. The phone sends the weight data to a server, which in turn notifies a provider to call the patient and somehow prevent him from getting worse and showing up in the ER. It was never clear to me how the provider was going to fix worsening CHF over the phone.

After Mr. Lane completed his presentation he joined 3 other panelists for a lively discussion moderated by a local physician whom I know. Some of these panelists described their devotion to mHealth with near breathless excitement. The physician moderator posed the ever-present question to the panel: “How do we get doctors interested in this system (and mHealth overall)?” The answers ranged from good – “Give doctors a product that is cost-effective” – to the ridiculous – “Align incentives by making physicians join ACOs.” The silliest thought of the night was the suggestion from one panelist that health care is no different from banking. I left the meeting with some concerns about who would pay for the Verizon system but decided to hold my reaction until I did a literature review. After all, I am no cardiologist and have not treated a patient for CHF since med school.

My review did not yield good news for Verizon or mHealth.

Turns out physicians have been working on home monitoring for CHF patients for years. Unfortunately their studies do not support remote home monitoring for CHF to reduce hospital admissions. A study from Yale Medical School published in the New England Journal of Medicine in 2011 randomized over 1600 CHF patients to either a control group or a remote monitoring group for outpatient care following admission for CHF. There were no differences in readmission rates for CHF or for any other cause over the 6-month study. Several other studies, including comprehensive reviews of existing literature, reach similar conclusions.

So what would a more realistic mHealth video look like?

Our CHF patient is discharged from the hospital all tuned up with appropriate medications, diet and smart phone remote monitoring using a CHF app. The monitoring app works well at first, feeding him periodic words of encouragement and reminders to take his meds, record his vital signs, weigh himself, etc. After several days of his phone going off constantly with all the reminders, alert fatigue sets in. After ignoring the alarms for a few days he gets fed up and shuts the CHF application off. The monitoring network detects the data interruption, and a provider calls the patient. At first the contact with a real human helps, but after several calls alert fatigue strikes again. Our patient recognizes the caller ID and stops answering.

In the meantime he tires of his medication regimen and diet restrictions and succumbs to the urge to scarf down some pizza and beer with some potato chips for dessert. His smart phone isn’t smart enough to change his behavior. The salt and fluid load makes his heart failure worse. In the middle of the night he wakes up short of breath and calls 911. Back to the hospital he goes.

The mHealth community is so enamored with their toys they can’t see what is right in front of them:

1. Peer-reviewed medical literature does not support the use of home monitoring for CHF patients. Period. LTE smart phones and glitzy medical apps do nothing to change that.
2. Without supporting literature no one is going to pay for remote monitoring. Who is going to cough up the dough for all those smart phones, Bluetooth connected home monitoring devices, remote servers, and the army of providers that will be required to manage the terabytes of data that such a monitoring network would generate? Neither ACOs nor any other ill-conceived “alignment of incentives” for physicians solve this issue.
3. The mHealth folks fail to recognize that monitoring is not the endpoint. The endpoint is changing patient behavior. A smart phone constantly shrieking warnings and reminders is rendered useless by alert fatigue. Patient behavior is a very tough nut to crack. The Verizon video ends with a nurse talking to the monitored patient about his weight gain. But that is NOT the end. It is just the beginning. No one knows what that nurse is supposed to say to change the patient’s behavior over the phone.
4. Like many mHealth ideas this system creates unrecognized changes to the standard of care and thus changes medical liability. What if our CHF patient who stops listening to alerts and stops answering the phone dies while he is in the monitoring program? Who is liable?

So it’s the same thing all over again with health IT. No proof of effectiveness. No way to pay for it. No understanding of the medical challenges involved. Unrecognized changes in standard of care and liability. Health care is not the same as banking. Duh.

Verizon has no business getting into health care beyond the LTE connection itself. They are going to lose their shirt investing in a treatment the literature says doesn’t work. Perhaps unwittingly, the physician moderator said it best when he asked the panel, “Where is the app that slaps my hand when I reach for the bag of Oreo cookies?”

Don’t get me wrong, folks. Our practice has enjoyed great success with EMR in over the past 7+ years. Our experience just scratches the surface of the awesome potential of health IT. I want you to succeed. But the health IT industry is headed in a direction that will guarantee failure. To succeed you must stop chasing pipe dreams and focus on the one goal that must be met before anything else – HIEs, mHealth or anything else – can succeed:

Find a reliable way for doctors to succeed with EMR in the office setting. Upgrade EMRs to reflect some understanding of the practice of medicine. Design patient portals that actually work. Demonstrate that EMRs are effective at improving care. Design a business model that shows the path to a return on investment.

Until that goal is met, nothing else matters.

Comments

[Yves Vimegnon, MD, MPH, FNLM]

mHealth and remote monitoring can work. However, anyone trying to leverage their potentials with a pure mechanistic approach stands to be disillusioned.
I always say that patients are not immune to alert fatigue. They are human being just as physicians. The crux of the matter is human behavior, as you seem to recognize. So, what do we do? We must continue to focus on lifestyle changes, patient engagement, and others in our designs. A comprehensive approach to designing an mHealth solution can yield a good ROI.
This field is in its infancy! We are all thinking and working hard on various frameworks and new conceptual models. Please note that socio-technical systems will always have some initial unintended consequences and weaknesses, partly because of the non-deterministic nature of human behaviors. Should you just stifle an emerging field for these reasons? No! Science and research do not work that way. Emergent properties or weaknesses will progressively be addressed with mitigation plans, PDSA cycles, more research and publications.
Once upon a time an increased mortality in a children hospital was attributed to the introduction of EMR. But it seems like you are enjoying some benefits of this same type of Health IT solution (EMR) in your own practice today. Remote monitoring and mHealth will get there. Sir, wait and see!

Your observations and comments cannot be discounted. They are good to foster R&D endeavors.

[Marlon Doglous]

You have really explained a lot of informative steps and reasons in case of the health sector. Verizon which will be the newest development in case of the health sector, I think will definitely affecting the patients of cardiac diseases. Since it responds for definite changes in the health care of the patient it is just or can be said as user friendly.