Tagged: mHealth

Things they didn’t teach in medical school: Part 30 Continuing the conversation after the consultation

One of the things they didn’t teach in medical school is how to continue to the conversation of the consultation after the actual physical consultation is over. Supposedly shared decision making leads to better decision satisfaction and outcomes but what happens once the patient leave the consulting room.

In some cases they leave with a pile of printed information. They may have taken their own notes. Or a carer may have taken the notes and been the second pair of ears. But I know the wrong messages may have been taken away or there will be lots of questions.

One way to deal with the problem is to ensure that the patients have had an opportunity to ask the questions in the first place – question prompt lists can help with this.

Another potential way is to provide a record of the consultation. This can be a written summary or alternately it can be an audio record of the consult. Some doctors are set up to do this but these days it most commonly happens when patients ask me if they can record the conversation and then they use their mobile phone.

An alternate potentially useful method is to develop your own resources to refer the patients to. I’ve just started, albeit extraordinarily slowly due to time commitments, to develop videos using the Explain Everything platform. Hopefully my patients will find these useful both for innformation about their treatment and to inform decisions.

Here is my talk on Xeloda Side Effects

Regulation of mHealth apps – let the debate begin

imedicalapps has reported that Apple may be starting to impose tighter restrictions on the approval of mHealth apps through the iTunes store. This follows on the appropriate oversight of the uCheck urine analyzer application (a way for automated reading of urine dipsticks).

The implication of the report is that Apple will only accept medicines information that is endorsed by the manufacturer of the medicine. Whilst this is a liability issue for Apple in some respects it is also fair guidance although one would argue that endorsement of the manufacturer might simply constitute dissemination of medicines information in accordance with the approved Product Information (PI) rather than written endorsement by the manufacturer.

Whilst such an approach is in keeping with law in actual medical practice a large number of medications are used according to valid evidence but outside information in the PI, also known as ‘the label’.

There is an urgency for a public debate about the best way to deal with this issue. Given the number of apps already in existence and the number of medications it is not likely that a regulator or an individual company has the resources to review everything in a timely fashion. The best approach might be to pursue (international) standards as proposed by organisations such as Happtique rather than a draconian regulatory approach.

Just as the NSA scandal has revealed the level of involvement of IT companies in our day to day lives we must also remember that these companies….Apple, Samsung, Google, etc, are now also the largest healthcare providers and the main conduits for health information both for practitioners and patients.

imedicalapps article


Should I give my patients homework?

A number of my colleagues have complained to me that patients expect so much of their doctors but don’t actually do anything in return – by this I mean they don’t actually follow the instructions of their doctors, take their medicines, listen to the advice, etc, etc.

Which leads me to the question – should I give my patients homework? We are meant to be in the era of patient/consumer empowerment. This means taking responsibility for one’s own healthcare (decisions). Doing homework might be a way of completing the deal.

Any doctor knows that his/her patients spend a lot of time consulting diverse sources to become health literate. This ranges from consulting aunt Mavis to asking the boys at the pub to searching the internet. Mostly it is searching the internet.

Rather than letting the patients search blindly and discovering somewhere in the corners of Google that Mexican Cafe Latte Enema Therapy cures cancer why not prescribe a homework program that actually sends people to reliable information and education?

Homework is used in cognitive-behavioural therapy to good effect. Maybe there are other applications.

Remote presence and the on call physician – now’s the time

In my previous post I wrote on the need for training for doctors who are on call.

Well now I want to turn that post on it’s head.

The problem with being on call is that when you take a call from the hospital you deal with an incomplete dataset. The dataset is mostly incomplete because hearing a description about a patient simply isn’t the same as seeing the patient yourself, taking the history yourself and examining them yourself. Sometimes what might seem straight forward decisions might be the wrong decisions simply because the gut feelings that come from the experience of seeing the patient first-hand is taken away.

There have been some limited forays into breaking down the barriers between the ED and the remote physician. ECGs can be transmitted to smart phones (I even knew a cardiologist who had a fax machine in his car for the same purpose). Blood results and radiology can be viewed over the web. But this still doesn’t bring the patient to the doctor.

This can now change with the advent of remote presence devices (RPD). The simplest explanation is that this is a drone or telemedicine robot. A RPD system consists of a remotely controllable mobile display screen and camera linked back wirelessly to the control station of a remote operator. The control station could be a desktop computer, a tablet or a smartphone. The operator (the on call doctor) can pilot the robot to the bedside of the patient and conduct a virtual consultation, perhaps with the assistance of a nurse, junior doctor or physician assistant to perform hands-on tasks like holding a stethoscope to the patient’s chest. The doctor and patient will be able to to talk to each other and see each other.

The bottom-line is that the on call scenario goes from the doctor on the end of the phone thinking “I’m not really sure how sick that patient is” to the doctor on the end of a video link seeing the patient and thinking “they don’t look right…..lets do x, y & z”.

Setting up a system might be less than a quarter of a salary for a junior doctor and the ROI is having the experienced doctor making decisions based on actually seeing the patient even if they aren’t in the building.

Examples that have already hit the market include Beam from Suitable Technologies and the InTouch Telemedicine System

Training prescribers how to prescribe mHealth apps

Sometime soon your doctor is going to prescribe you a mHealth app for your smartphone. There’s a 1 in 3 chance you already have one on your phone – for tracking calories, weight, exercise, your smoking, your blood sugar or our mood. How will you or your doctor know which is the right app?

Well at the moment nobody really knows. Intuitively, tracking your health with apps might help you to achieve your health goals but strictly speaking nobody really has built the evidence-base. In fairness to the evidence builders, the iPhone has only been around for 5 years and “there’s an app for that” was first used on Jan 29, 2009. Preliminary evidence suggests current mHealth apps aren’t really designed for health promoting behaviour change http://www.jmir.org/2012/3/e72/
Nonetheless, the market is out there. Happyique is already piloting a portal for app prescriptions…..reimbursement for prescription to follow http://www.happtique.com/mrx/
Your doctor hasn’t been trained in health behaviour change – this is a new job for medical school. Standards are needed – Happtique has started this work – they need to be grounded in evidence and sound from the perspective of psychology and behavioural economics.
How to move forwards? Teach medical student about behaviour change. Regulate apps according to evidence but with a light touch. Teach consumers to find reputable, independent apps.