This article titled “Are medical apps on your smartphone good for your health?” was written by Mark Honigsbaum, for The Observer on Monday 10th March 2014 09.00 UTC
On a dreary November afternoon, the news bulletins are dominated by the fallout from the Mid Staffordshire hospital scandal and predictions of another tough winter in A&E departments but, at LSO St Luke's, a church turned concert hall in Old Street, east London, all is optimism and light.
The NHS may be lurching from one crisis to another but, to listen to the entrepreneurs gathered beneath the eves of this Hawskmoor-designed church a stone's throw from tech city, the health cavalry is on its way.
Twenty health tech startups from around Europe have gathered at St Luke's to pitch to a panel of venture capitalists in a Dragons' Den-style competition. Up for grabs is a share of a €50,000 prize and the ear of an investor who can fast-track their device to market. The event's sponsors, Johnson & Johnson, have billed it as a digital health masterclass.
First up is Johann Huber, co-founder and CEO of Soma Analytics, a London-based company that describes its product as the "world's first evidence-based mobile resilience programme". In plain English, Huber and his partners have developed a smartphone app that purports to measure employee stress levels by analysing their speech and texting patterns.
"Using our algorithm we can design a 21-day personalised programme to help employees manage their stress and build mental resilience," he tells the dragons.
Next up is Paul Doherty, head of sales at Shimmer, a Dublin-based company specialising in "clinical grade wearable wireless sensing technology", such as the Shimmer3, a slimline sensor that can be strapped to an athlete's arm in training to provide coaches with biophysical data.
Doherty is followed by Andraz Ogorevc, a Slovenian entrepreneur pitching a mobile app and Bluetooth-enabled wristband that enables the wearer to send an SOS message within 20 seconds of suffering a heart attack. "The market is huge. We estimate there are 1.2 billion smartphone users with health conditions," he says. "Our goal is 20 million users within five years." The star of the afternoon, however, is Don Jones, vice-president of Qualcomm Life, a subsidiary of the chip maker Qualcomm and a big sponsor of wireless healthcare technology. In a slick 30-minute presentation, he takes his audience on a whistlestop tour of the fast-changing market for health apps and digital medical devices – a market predicted to be worth bn by 2017 in the US alone.
From the LifeWatch V, a smartphone embedded with sensors that enables users to monitor everything from body temperature and ECG to heart rate and oxygen saturation, to the YOFimeter, a compact wireless blood glucose meter for diabetics, Jones explains that new technologies are rapidly altering how, when and where people monitor and manage their health.
"Think of every way you have ever interacted with a medical professional or someone in a clinical setting – a doctor, a nurse, or your corner pharmacist – then think how that can be replicated digitally so that the process is both more convenient and faster," he says. "The odds are that someone in Silicon valley is already working on it."
To spur innovation, last year Qualcomm announced a m prize for a Star Trek-style "tricorder" to be awarded to the first developer to succeed in designing a mobile platform capable of diagnosing a set of 15 conditions, including pneumonia, diabetes and sleep apnea, without recourse to a doctor or nurse.
While that might sound like science fiction, 230 teams from more than 30 countries have registered interest. But you don't have to upgrade to a device like the LifeWatch V to monitor your vital signs. If you have the latest smartphone you can probably achieve the same thing with an off-the-shelf plug-in sensor and a downloadable app. Indeed, Jones argues that it is only a matter of time before mobile medical technologies make booking an appointment with your GP for a blood pressure test obsolete.
"Imagine a future where every medical need is just a button away and you can access medical support whenever and wherever you need it," he explains. "In other words, no more queuing for appointments or sitting in waiting rooms."
Put that way, digital health sounds hugely attractive. After all, in a world where many people already use the internet to research their symptoms, waiting for your GP to order a test and refer you to a specialist can be hugely frustrating. In theory, digital health can sidestep that process by putting the same clinical expertise on a device that sits in your pocket or on a smartpatch attached to your skin and streaming the data wirelessly to your "care provider network".
Similarly, more basic telehealth devices that allow the remote monitoring of patients with long-term health conditions have the potential to allow huge cost savings for the NHS by enabling nurses to manage patients with heart and weight issues or conditions such as chronic obstructive pulmonary disease (COPD) more efficiently in the community.
But do we really want to live in a brave new digital world where patients are their own doctors and there is no longer a need for us to submit to an interview in a clinical setting? What do we give up – and what do we lose – when health becomes nothing more than a stream of physiological outputs, a set of data to be parsed and quantified by algorithms managed by faceless medical providers?
Furthermore, what evidence is there that these technologies are suitable for every patient or that they will result in better medical outcomes? Isn't there a danger that by inviting ever more intrusive digital surveillance we become slaves to technology rather than the masters of our own health?
There is nothing new about the self-monitoring of bodily functions. People have been examining their urine and stools for signs of disease since Roman times and, after the association of diabetes with excess sugar in the early part of the 19th century, the English physician and physiologist George Oliver began marketing a range of urine reagent papers for home use in 1883. The self-monitoring of diabetes took another leap forward in the 1970s with the production of the Ames Reflectance Meter, a 1.2kg battery-powered lead case featuring a moving needle that indicated blood glucose levels within about a minute of being operated, and by the 1980s the home management of diabetes using handheld glucose metering systems had become standard. The 1980s also saw the aggressive marketing of the first digital home blood-pressure monitors by companies such as Omron, spurred by mounting concerns about heart disease and the risks of hypertension, and by the end of the decade many women's bedside drawers contained a pregnancy testing kit.
By the 1990s, as people became used to viewing health in terms of a set of risk factors and as multiple drug regimes for the management of long-term medical conditions became commonplace, so the notion of regular checkups and tests, in which vital signs are monitored as a matter of course, began to be seen as normal.
In retrospect, however, the key development was the launch of the iPhone in 2007, followed a year later by the 3G version and the opening of Apple's app store. It soon became clear that with its built-in camera, audio and GPS mapping functions, the iPhone was much more than a mobile phone, it was a sophisticated self-tracking device – hence its adoption by the Quantified Self movement to record and track every facet of members' lives. Factor in the ability to download the latest exercise and diet apps and it was only a matter of time before people would be using their smartphones to quantify health data too.
Qualcomm was one of the first chip makers to recognise the potential to transform healthcare – hence its decision in 2005 to set up the Wireless Life Sciences Alliance in San Diego with Don Jones as chairman.
At first, Jones concentrated on the development of wireless and connected health solutions to support research in the life sciences. But as the smartphone market took off and app developers began targeting health and medical needs, he soon realised the consumer market had much bigger potential.
He also had a personal interest. His son, Keenan, was born with a congenital heart defect and needs to monitor his heart regularly to check if his heart is beating normally. For years, Jones would drive Keenan to a cardiologist to be hooked up to a Holter monitor to measure his arrhythmia. But in 15 sessions, Jones claims the conventional Holters failed to produce any useful data.
"Finally, I got fed up and told the attending nurse, 'you know we're not going to have any more of your Holter monitors'," says Jones. Instead, he used his industry contacts to test a series of prototype electronic monitors capable of giving continuous ECG readouts. It was one of these non-US Food and Drug Administration approved prototypes that eventually produced the ECG data his doctor required to decide whether Keenan needed an ablation or therapy.
Keenan, who is now 19, takes his own ECG readings every day using an AliveCor heart monitor that connects to his iPhone. If he's away from home and his heart starts racing – as it did on a recent trip to Montana – he can email the readings directly to the nearest hospital, together with his medical history, confident that the correct medication will be waiting for him on arrival at the emergency room.
Data can also be sent automatically via the cloud to a patient's health provider to order a new test or prescription using systems like Qualcomm's 2net. Indeed, many doctors now prescribe apps, rather than drugs, so that patients can keep abreast of treatment protocols. Taking this idea further, Jones foresees a time when apps will also "prescribe doctors", telling patients which specialist they should consult and how to contact them. As patches and monitors become smaller and more lightweight, he even envisages a time when vital sign data will be collected seamlessly, 24/7, without the need for the patient to take an active role. The next stage is to combine this vital sign data with other predictive data – such as genomic markers for conditions like breast cancer – to devise personalised treatment programmes tailored to a patient's risk profile.
From a conventional medical standpoint, the rise of digital medicine is worrying, say some. This is not only because apps and smartphones have the potential to marginalise expertise, making it harder for doctors to cash in on their medical training. Giving people the ability to monitor their vital signs, it is argued, also risks generating needless anxiety.
As Dr Nick Mann, a GP with 22 years experience in an inner city London practice, puts it: "Monitors used around the clock may throw up false alarms. For example, an ECG monitor may throw up all kinds of arrhythmias over 24 hours. It can be disempowering for patients as the patient and staff switch to ministering to the production and influx of data rather than focusing on the doctor-patient relationship."
Mann also questions whether such technology is beneficial for patients who are terminally ill. "The main priority for someone with end-stage COPD or advanced diabetes is the rest of the life they have left," he says. "People don't really want to be reminded of their illness day by day. What they want is to get on with living as healthy a life as possible."
But perhaps the biggest objection is that these technologies may not necessarily result in more cost-effective medical care – a critical consideration in the context of a tax-payer funded system, such as the NHS, where investment in new technology must be justified on clinical and financial grounds.
Perhaps this explains why in 2009 the Department of Health agreed to fund the Whole System Demonstrator project – a randomised trial of 3,230 patients with diabetes, COPD or heart failure at 179 practices across southern England that compared emergency hospital admissions and mortality rates for those using teleheath devices with those using the usual care systems.
Preliminary findings, in 2012, suggested a 45% reduction in mortality and a 20% fall in emergency admissions for telehealth users and prompted Paul Burstow, then minister for care services, to sign a concordat with the telehealth industry and launch a campaign, 3millionlives, with the aim of rolling out telehealth devices to three million people by 2016, to save the NHS an estimated £1.2bn.
However, a more detailed followup analysis by the Nuffield Trust, published in the doctors' journal the BMJ later in 2012, found that when the first three months of data were excluded the differences between hospital admissions and mortality in the two groups was negligible.
Worse, researchers found that differences in hospital costs between the two groups were also insignificant and that given the high startup costs of telehealth systems they were unlikely to generate anything like the projected savings. Since then, little has been heard of the government's three million lives initiative and to date only 100,000 telehealth devices have been distributed to patients with long-term medical conditions.
Nevertheless, pilot trials are continuing in several NHS trust areas and, for those patients fortunate enough to have been recruited, the devices have been transformative. Take Haris Patel, 53, from Folkestone, Kent, who suffers from Parkinson's, peripheral vascular disease and hypertension, as well as other conditions. Patel, who is confined to a wheelchair, used to be a regular user of Kent Medway emergency services. Since taking possession of a Viterion 500 telehealth monitor, however, he has been able to monitor his blood pressure, weigh himself regularly and send his blood sugar readings to his hospital for remote viewing by specialist nurses, reducing the need for emergency callouts. "I used to spend an average of eight to 10 months in hospital every year," he says. "Now, when my blood pressure is high it can be dealt with instantly without the need to involve a consultant. It's improved the quality of my life 100%."
Patel says the machine has also given him a greater understanding and control of his condition and looks forward to the time when he can send the same data wirelessly.
Many consultants are also beginning to embrace the technology. At the Johnson & Johnson digital health masterclass, Dr Jon Shaw, a former surgeon, was pitching DocCom, a secure social networking platform for use by medical teams in hospitals. DocCom was born out of Shaw and co-founder Dr Jonathan Bloor's frustration with hospitals' reliance on bleeper and paging systems.
Why, they wondered, couldn't the NHS have a system akin to Facebook that enabled consultants to communicate with colleagues outside ward rounds? By signing up to DocCom's secure cloud-based platform, consultants can do that without the fear of breaching patient confidentiality. All they have to do is download an app to their mobile phone and confirm their identity in order to start texting colleagues straight away. So far, 10 NHS trusts have agreed to trial the system.
Another promising application is Safe Mobile Care. Devised by Dr David Morgan, a consultant head and neck surgeon in Birmingham, the system uses a touch-screen mobile phone that can be programmed with personalised plans for patients. Morgan claims that not only does the system reduce admissions for cardiac failure by about 80%, it also enables nursing teams to work more efficiently. Furthermore, rather than increasing patient anxiety, he argues the system helps patients to better understand their conditions and take control of the management of their health.
Morgan does not believe, however, that the technology is appropriate for all patients. "The idea that patients should have a device for life is a market-led idea to sell more devices than necessary."
That sentiment was echoed at the masterclass at LSO St Luke's. Although nearly every developer claimed patients' needs were uppermost, the judges begged to differ, expressing concern that some startups seemed more focused on market share than in catering to a clinical need. Perhaps that explains why the dragons awarded the first prize to PxHealthCare, a Dutch startup whose product was developed specifically for breast cancer patients. Founded by Dr Anne Bruinvels, a pharmacist with a background in personalised medicine, the company aims to provide bespoke medical support to cancer patients by providing them with a suite of self-reporting tools. Using the company's OWise app and web platform, patients can talk to their physicians and get advice about their drug regimes, enabling them to better manage their treatment plans.
At the same time, the data collected by OWise can be anonymised and shared with medical researchers to shed light on drug interactions and side-effects.
For these and similar applications to take off in the UK, however, developers will first have to convince sceptical GPs like Dr Mann. While Mann accepts that some patients may benefit from such devices, he doubts this is true of most patients he sees in his practice.
"As a doctor, I welcome anything that will improve patient care and be cost effective but so far the evidence from telehealth is that it doesn't do either of those things," he says. "In the NHS we haven't got the luxury of giving people things just because they like them."
For all that doctors may be reluctant to embrace these new technologies, however, social trends are not with them. Already, Britain and the US are facing a shortfall of doctors as the recruitment to medical schools fails to keep pace with an ageing population and the growing numbers of people living with long-term health conditions.
Back at St Luke's, I ask Jones whether he thinks the medical profession will come round to digital health. "As with any new technology, you're going to find early adopters and late adopters and a middle group who hang back," he says. "I'm not sure it's what all physicians want but I'm confident that a percentage of them will wholeheartedly embrace this technology and that eventually the rest of their colleagues will follow."
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