In this excerpt from his book « The Patient Will See You Now: The Future of Medicine Is in Your Hands » cardiologist Eric Topol, chief academic officer for Scripps Health in San Diego and an acclaimed research scientist, describes how technological breakthroughs will enable patients to take a leading role in overseeing their care and accelerate a dramatic rethinking of hospitals’ role in society. This will result, he says, in greater empowerment of patients and an overall improvement in their quality of care and outcomes.
Way back in 1996, the « Seinfeld » TV show told the story of Elaine, who developed a skin rash. Doctors kept refusing to see her. The problem was that a doctor had called her « difficult » after an appointment four years earlier when she had not wanted to change into a gown to get a mole examined. She wanted to have her chart delete this discredit, but the doctors wouldn’t cooperate. So she worked with Kramer, who posed as Dr. Van Nostrand to try to steal her chart. That backﬁred. She never got her diagnosis or chart. The segment is hilarious and at the same time sobering since it’s a slice of medical life.
Now fast-forward to two decades later. Doctors still label patients as difficult. But a new model is taking hold. If Elaine wanted to have her skin rash assessed today, all she would have to do is take a picture of it with a smartphone and download an app to process it. Within minutes, a validated computer algorithm – more accurate than most doctors – would deliver, by text, a diagnosis of her skin rash. The text would include next steps, perhaps treatment with a topical ointment or a visit to a dermatologist for further assessment. When seen by a doctor, she could demand a copy of her office visit notes and also request to review and edit them. Most likely, however, she wouldn’t have to see any doctor. She’d have immediate access, at any location, to a diagnosis of her medical condition.
The difference between these two scenarios represents the essence of a new era of medicine. It is powered by unplugged digitization, with the smartphone as a hub. We can now stuff over 2 billion transistors into a smartphone, so anywhere there is a mobile signal individuals can perform various components of a physical exam – including all vital signs, skin, eyes, ears, throat, heart and lungs – and run lab tests and capture real-time biosensor metrics.
Patients can take blood pressures or blood glucose measurements via smartphone.(William Duke for USN&WR / Bigstock)
Today, any person can take blood pressures or blood glucose measurements, or even an electrocardiogram via smartphone. The data are immediately analyzed, graphed, displayed, stored and, at the discretion of the individual, shared. The ﬁrst time I had an ECG emailed to me by a patient with the subject line « I’m in atrial fib[rillation], now what do I do? » I knew the world had changed.
The patient’s phone hadn’t just recorded the data – it had interpreted it! A smart algorithm was now trumping one of my skills as a cardiologist. Putting this power in everyone’s pocket could pre-empt an emergency room visit or an urgent clinic appointment.
Other experiences over the past couple of years, attending to airplane passengers in distress, have reinforced my sense that medicine has already transformed. The ﬁrst passenger was having chest discomfort and sweating; I was able to conﬁrm with a mobile phone electrocardiogram that he was having a heart attack, which led to an emergency landing. A ﬂight attendant or any other passenger could have done the same thing.
Were there any ambiguity, the ECG could have been wirelessly sent from the plane to medical personnel on the ground to help make the call. A young woman having a panic attack with difficulty breathing and a very rapid pulse was the second passenger. The ECG showed atrial fibrillation, with a heart rate of 140, and upon questioning her it was pretty clear she had an overactive thyroid, later conﬁrmed. An amalgam of verbal reassurance and handholding was all that was needed. Neither passenger required a doctor on the plane to make the diagnosis, just the tools to collect the data.
All of this data generated by smart, hyperconnected patients represents a serious challenge to medical paternalism. No longer will M.D. stand for medical deity. You will still see doctors, but the relationship will be radically altered. In the new model, the patient becomes the chief operating ofﬁcer, monitoring all the operations of his body, and getting all relevant data rapidly analyzed and reported back directly to him. The COO reports periodically to the doctor, the CEO, who really doesn’t want to be bothered unless it’s important. When that occurs, the CEO is ready to plug in with all her experience, knowledge and wisdom to deal with a problem.
We’ve never seen such a discrete challenge to the medical profession because we’ve not had the platform – the smartphone – or landscape for that to be accomplished. Today, for example, at the University of Pennsylvania, there is a Working Dog Center where Dutch and German shepherds have shown 90 percent accuracy in detecting ovarian cancer. Building on this exceptional canine capability, multiple companies are testing smartphone « electronic nose » sensors to detect cancer via breath, including ovarian, lung, liver, gastric, breast, colorectal and prostate. Such breath sensors are also being tested to quantify other metabolites that would be linked with particular diseases, such as nitric oxide for asthma. These new products are the precursor to an unbridled capability for across-the-board lab testing anytime, anywhere.
With all the fragmentation that exists with electronic medical records today, perhaps the last thing that is needed is a new, major stress on the system. But with well over 25 percent of Americans now tracking at least one health parameter on some type of wireless device, and hundreds of mobile apps commercially available to capture user-entered medical data, this is an area that is ready to explode.
Some health systems are paving the way for the ﬂow of such data. For example, Banner Health in Arizona is offering a wireless scale, pulse oximeter, breath ﬂow monitor, blood pressure cuff, and glucometer to some patients and has established a portal for viewing the results and providing guidance. Access Community Health Network in Chicago has adopted a similar model. One physician said it was « like having a doctor not only in your house but in your pocket. This is a revolutionary change in medicine. »
This revolution, Topol notes, will certainly extend to hospitals. In recent years, the imperative to lower health care costs, and to reduce patients’ exposure to risks such as infections from being hospitalized, has encouraged medical centers to discharge people as soon as possible. Technology will only speed this trend, as individuals are able to handle more of their care at home.
When I was training to be a cardiologist in the 1980s at Johns Hopkins, it took three hospital days for a patient to undergo a cardiac catheterization. Today, the patient can get up and walk right from the cardiac catheterization lab table and go home a few hours later. This is just one of hundreds of examples of procedures or operations that used to require hospitalization but now are routinely being done on an outpatient basis. For those operations that do require hospitalization, the typical length of stay has dropped dramatically. These factors, at least in part, account for the marked reduction of the number of hospitals in the United States, which peaked in 1975 at 7,156 and has steadily reduced to 4,995 in 2013, representing over a 30 percent decline.
But that is just the beginning. In fact, hospitals as we know them today will eventually be extinct.
The hospital room of the future will be the bedroom. Biosensors will record continuous vital signs and any other relevant physiologic metrics; little mobile devices and smartphones will enable both communication and examinations. Smart pillboxes and other tools will monitor treatment adherence; personal emergency response systems will summon an ambulance; and tiles with motion sensors will monitor patients’ gait.
Indeed, a smart medical home can easily be designed. A research group in Sweden conceived the sensor architecture for remote long-term medical monitoring at home and has already tested it for over a year, with almost 15,000 sensors placed. These include sensors under a mattress, motion sensors in each room, and many sensors to monitor everyday activities. In Denmark, remote monitoring and videoconferencing play a large role in end-of-life care. More than half of patients used to die in the hospital; now over 92 percent die at home.
Certainly, there are challenges facing at-home hospitals. A comprehensive system that uses many digital medical tools would lead to a deluge of data that would need to be integrated and processed. Further, smart medical homes would have to be individualized for particular patients and their concerns. And the data collected have to be secure and the systems must safeguard privacy and identity.
The privacy story goes beyond protecting digitized medical data from being hacked; it must also be in an individual’s control. Many might feel as if they were invaded if they are required to wear sensors around a home that is always tracking them. For this reason, a fully equipped smart medical home should not be used for long periods of time. Most folks wouldn’t want their home to become a digital dystopian environment, but to pre-empt a hospital stay they would likely be willing to have Big Medical Brother peering in.
Also, unlike many home entertainment systems, with their multiple remote control devices that most people can’t ﬁgure out, these smart homes need to be exceptionally easy to use. And they must cost less – far less – than today’s outrageous hospital bills. For the more than $4,000 per day that is charged for a non-ICU hospital room, one can afford to do a lot of remote monitoring in the convenience of one’s own home – a sanctuary away from serious infections.
There is no replacement for the acutely ill patient who is admitted to an intensive care unit or the emergency room. Likewise, surgeries and procedures, medical imaging and laboratory facilities would still have a place in the hospital of the future. But all the non-ICU hospital rooms, which represent the majority of most hospitals’ ﬂoor plans, would no longer be necessary. Most patients who used to be housed in these rooms would simply be remotely monitored.
So what do we do with the bulk of current hospital space when the transition to smart medical homes is accomplished? Some might close or become part of the ongoing and extensive consolidation of hospitals. The new hospital at the Navy’s Camp Pendleton base in California, for example, has only 67 beds in its 497,000 square feet.
Even more noteworthy is the new Montefiore Medical Center in New York City, which has 280,000 square feet, 11 stories, 12 operating rooms, an advanced imaging center, laboratory and pharmacy services – and no beds! Its president and CEO, Steven Safyer, proclaimed, « We are reshaping outpatient care and establishing leading practices that provide [health care services] through multidisciplinary teams at a hospital without beds. »
One signiﬁcant new opportunity is for the hospital to become a data and information resource center. While such centers could be quite remote from the patient or run by large dedicated companies, there is considerable advantage for having the data center proximal to the patient. There would be familiarity with the patient via the doctor and staff caring for the individual, be it during a recent hospitalization or by providing primary care. The staff of such a monitoring center could represent the future « hospitalist » – a physician particularly trained and adept at the interface of machines and people. You might describe them as geeks with compassion.
In short, we’re seeing an unprecedented shake-up in a paternalistic profession that has never been seriously challenged since the era of Hippocrates, 400 B.C. As in every other sector of our lives, when data becomes eminently portable and granular, when there’s so much more of it and it’s free ﬂowing, fully transparent, and there’s seemingly unlimited computing power to process it, historic change takes place. The world of health care is being irrevocably transformed.
Excerpted from » The Patient Will See You Now: The Future of Medicine Is in Your Hands » by Eric Topol. Available from Basic Books, a member of the Perseus Books Group, copyright © 2015.
Excerpted from U.S. News’ « Best Hospitals 2016, » the definitive consumer guidebook to U.S. hospitals. Order your copy now.