By KENT BOTTLES

Physician executives who ignore smartphones and their healthcare applications will miss the most important disruptive technology trend in the next five years. Physician executives who understand how smartphones will transform the industry for providers, payers, patients, and employers will thrive in their careers.

Rajeev Kapoor, a former executive at Verizon, describes the smartphone-enabled transformation: “The paradigm of healthcare has changed. You used to bring the patient to the doctor. Now you take the doctor, hospital, and entire healthcare ecosystem to the patient.” (http://ow.ly/3GIir) Susannah Fox of the Pew Research Center’s Internet and American Life Project offers a specific example when she talks about the celiac disease patient who uses her smartphone to evaluate food products in the grocery store.

“You cannot call your gastroenterologist every time you buy a new product.” (http://e-patients.net/index.php?s=fox) David Jacobson of Wellpoint notes that “The technology of telehealth is well ahead of the socialization of the telehealth idea and we are at a tipping point for utilization to begin taking off.” (http://ow.ly/3GIir)

The Global mHealth Developer Survey found that today 78% of respondents said that smartphones offer “the best business opportunities for mobile healthcare” in 2011; by 2015, 82% said smartphones would dominate the industry. Cell phones, tablets, and PDAs trailed smartphones in popularity according to the survey. (http://ow.ly/1aVf9V)

Smartphones run on a specific operating system and can download applications (apps) that run on the operating system. The most popular operating systems in the United States are iPhone, BlackBerry, Windows Mobile, Palm, Web, Symbian, and Android. (http://ow.ly/3GIwf) We are just beginning to discover how to harness the smartphone’s computing power, cameras, audio, video, motion sensors, and GPS functions to better manage health and wellness. (http://ow.ly/3gVzg)

In contrast to the rather slow adoption rate for both health information technology and personal health records, smartphone use is skyrocketing. In October 2006 15% of Americans owned a smartphone; by December 2009 that number was 42%. Surprisingly, one report noted that the smartphone market was “unfazed by the recession.” (http://ow.ly/3GIwf) In late January 2011 Apple reported that someone downloaded the 10 billionth app for the iPhone. (http://ow.ly/3IlLY) That lucky smartphone user received a $10,000 gift card to the iTunes store.

Why are smartphones so popular? The ability to carry around a handheld computer that is user-friendly and that allows users to do things anywhere at any time is attractive. One research whitepaper coined the term “care anywhere” for smartphone-enabled health care. (http://ow.ly/3GIir) But it has to be more than just that when people routinely say they “love their iPhone.”

MIT’s Sherry Turkle in her book Evocative Objects: Things We Think With writes “We think with the objects we love, and we love the objects we think with.” She also emphasizes how important it is that we carry this “second self” with us at all times. Mark Rolston, chief creative officer of Frog Design, observes that people grieve when they lose a personal electronic device. “You are leaving your brain behind,” he says (http://ow.ly/3jjCG).

Joseph Kvedar, MD, director of the Center for Connected Health at Partners HealthCare in Boston, states that humans find it easy and natural to anthropomorphize pet rocks and tomagotchis, and that we are truly forming trusting relationships with our smartphones. (http://e-patients.net/index.php?s=fox) In her new book, Alone Together: Why We Expect More from Technology and Less from Each Other, Turkle explores the positive and negative consequences of this love affair with smartphones and other forms of technology.

Demographics will also drive increased use of smartphones in health care. The first of the 78 million baby boomers will turn 65 in 2011 and as the sandwich generation who are concerned about the welfare of their children and their parents, they know the importance of health and wellness. Boomers also lead all generations in technology spending, and they will use smartphone technology to foster ongoing independence for themselves and to care for their relatives who live across the country. John Sherry, Director of User Experience Design for Intel, observes, “A number of economic, generational, and societal factors combine to make boomers likely early users of remote health monitoring and management products.” (http://ow.ly/3GIPJ)

Smartphones will transform healthcare by offering solutions in four classes of activities: communication, transactions, knowledge, and integration of information. (http://ow.ly/3GIir)

Communication

Communication between all players in the healthcare space will be changed by the use of smartphones. The most obvious arena to examine is the patient/doctor relationship. People who access scientifically sound advice through their smartphones wherever they find themselves can become more independent, empowered, self-managing patients as the above celiac example shows. Smartphones also make patients more likely to participate in online conversations with other patients on social media websites like PatientsLikeMe and DiabetesMine. Patients want to communicate with their physicians via email, but physicians have been slow to accommodate this desire. Although many consumers have not been able to use smartphones for communication with their provider, 85% of those that have connected with their doctor by means other than face-to-face were satisfied with their discussion. (http://ow.ly/3GIir)

Physicians worry about patient compliance, and 88% would like their patients to be able to monitor their weight, blood sugars, and vital signs on their own. 66% of physicians said they would like to use email for administrative communications like appointment reminders, but only 23% of consumers preferred communication by email for such simple communications. (http://ow.ly/3GIir) Forty percent of physicians said 30 percent of office visits could be avoided with the use of remote monitoring, email or text messaging with patients. (http://ow.ly/3GIPJ) A Mayo Clinic two-year study found that e-visits could replace in-office visits in 40 percent of 2,531 cases. (http://ow.ly/3GIir)

The Good Shepherd Health System developed their own iPhone app to help physicians access medical records, track vital signs, order medication, and coordinate care with other team members. Physicians from Duke, Harvard, and the John Theurer Cancer Center have worked with Zibbel, a health solutions technology company, to create a smartphone enabled virtual network for mobile cardiology and oncology consults between experts. (http://ow.ly/3GIir)

Smartphone technology can also change and improve communication between consumers and their pharmaceutical companies, health plans, employer, and health system. Michael Mathias, Aetna’s chief technology officer comments, “The days of mass communication are over. We can now deliver customized communications through mobile apps, online, telephonically, or through mail based on our understanding of how each member wants to be communicated with.” (http://ow.ly/3GIir)

Kaiser and Mayo are both developing smartphone apps to help patients managing chronic conditions and healthy consumers who want to stay fit. Scott Eising of Mayo Clinic says, “We’re a very content-oriented organization. In our research into the mobile health consumer, we found that people are looking for very action-oriented information.” Mayo Clinic has launched Mayo Clinic Meditation and Symptom Checker iPhone apps so that we can “take care of patients here and ‘there,’ whether at home or at work.” (http://ow.ly/3GIwf)

Qualcomm is creating “the clinic without walls” to take care of its 12,000 employees in the San Diego area. Using the Myca Health platform, Qualcomm’s health staff can consult remotely with mobile employees via smartphones. “People are so connected to phones, they’re an extension of themselves. You can’t have your doctor with you all the time but the phone can keep you on the right path toward health and wellness,” states Dr. Marion Zabinski. (http://ow.ly/3GIwf)

Merck Serono has developed a smart electronic injection device with two-way Bluetooth communication functions that track all injections made by the patient. When an injection is missed, nurses contact the patient to remind them to adhere to the treatment plan. (http://ow.ly/3GIir)

Transactions

The ability of consumers to use smartphones to book a flight or make a hotel reservation has revolutionized the travel industry, and many predict health care will soon follow suit.

The first area in healthcare that has utilized smartphones for transactions is e-prescribing. The most common prescription orders that a doctor uses can be automatically populated on their smartphone. Donald Burt, MD, chief medical officer of PatientKeeper, says their 25,000 physician users spend 20 percent of their time on their smartphone. Trusted nurses can post prescription order request on smartphones, and the physician can modify or approve the order no matter where they are located physically. A PricewaterhouseCoopers 2010 survey found that over 80 percent of both specialists and primary care doctors were interested in e-prescribing using their smartphones. (http://ow.ly/3GIir)

Aetna has made transaction functions such as physician finder and claims check available on smartphones. CVS Caremark has iPhone apps for prescription drug information and patient management of drug refills as well as for retail location finder functions. (http://ow.ly/3GIir)

Knowledge

Allowing physicians to have access to the latest evidence-based medicine knowledge at the point of care may be the most exciting and important application of smartphone technology. In a national survey, one third of physicians responded they make decisions based on incomplete information in nearly 70 percent of the patients they see. (http://ow.ly/3GIir) Lay people are also utilizing this technology to become wiser consumers of health care.

Epocrates is perhaps the best example of a mobile reference resource that physicians turn to in real time for information about the patients they are seeing right now. Epocrates’ drug reference app is the most popular free medical download for iPhones, and one study documented that 60 percent of Epocrates users avoided three or more medical errors a month. More than 125,000 doctors use Epocrates on iPhone and iPod touch devices. (http://ow.ly/3GIwf)

UpToDate is another evidence-based, peer-reviewed information resource available via smartphones. Over 400,000 providers use UpToDate for their synthesis of the medical literature, the latest studies, and treatment recommendations. (http://www.uptodate.com/home/index.html)

Skyscape has put together the largest library of medical resources that is available for smartphones, and the Medical Encyclopedia from the University of Maryland was one of the top ten free apps in the iTunes Store in December 2009. FDA Recalls is a free app for iPhones that keeps clinicians on top of which products have recalled by the manufacturer. (http://ow.ly/3GIwf)

Diagnostic tools for clinicians are too numerous to catalog. Examples include Diagnosaurs for general diagnosis, ARUP Consult for laboratory, OsiriX for digital imaging, Instant ECG for ECG interpretation, Vigilance for Emergency room situations, AirStrip OB for obstetrics, and American Well for remote physician consultations. (http://ow.ly/3GIwf)

Consumers are also using smartphones apps to keep abreast of medical knowledge. The Evincii app matches symptoms to over the counter medications, and the Mayo Clinic Symptom Checker iPhone app became available in early 2010. (http://ow.ly/3GIwf) Consumer interest has been highest in fitness and weight control apps (Tap & Track, iTreadmill, Walk It! And Pedometer-Widget), Diabetes Management (Glucose Buddy, Handylogs Sugar), High Blood Pressure Management (HeartWise, My Blood Pressure and Heart Rate), sleep hygiene (Sleep Cycle Alarm Clock, Smart Alarm Clock), Stress Reduction (Stress Free with Deepak Chopra, Rage Eraser), and First Aid (Pocket First Aid & CPR). (http://ow.ly/3gVzg)

Integration of Information from Diverse Sources

Perhaps the biggest challenge for both consumer and physician is how to integrate all of this information that is available via smartphones. It truly is like drinking from a fire hose, and the amount of information can be overwhelming.

Health systems have been focused on implementation of the electronic medical records, and the Patient Protection and Affordable Care Act has provided billions of dollars to support rapid adoption. Unfortunately both the hospital systems and the Office of National Coordinator have largely ignored the importance of integrating mobile health into other health information technology efforts. For example, two thirds of physicians in a national survey said they were using smartphones in their practice that are not connected to either their office or hospital HIT systems. Thirty percent of physicians said their health systems or medical group would not provide support for smartphones. (http://ow.ly/3GIir)

Many physicians and hospital administrators, tired of wearing multiple devices on their belts, have wanted their IT Departments to consolidate all messaging functions to smartphones. Most hospitals already have invested in pagers, cell phones, Vocera badges, SpectraLink Wi-Fi phones, and two-way radios, and what works for maintenance staff may not work for ICU nurses. A research white paper reporting on the experience of smartphone early adopter hospitals recommends supporting a variety of devices at the present time, but it also warns against being too slow to adopt smartphones. It also points out that work processes have been designed around the currently employed technologies and replacement by smartphones will necessitate work process redesign which may result in cost-savings. (http://ow.ly/3HalT)

Smartphones in health care will not live up to their full potential if integration is not successful. No matter how many readmissions for congestive heart failure remote weight monitoring at home could avoid, such programs will fail if the information does not appear in the office or hospital medical record.

Joseph Kevdar, MD, director of the Center for Connected Health at Partners HealthCare, stated that while “sensor technology may be rapidly becoming commoditized, integration with EMR and data aggregation systems is not something we have done well. We need to get better at gathering information, adding logistical software to get to the intersection of all the data and population health management.” (http://ow.ly/3GIir)

There are technological advances that are promising, according to Kvedar. Emotional sensors predict the patient’s mood by analyzing their voice (Cogito) or by facial recognition (Affectiva). Bodytrace’s wireless weight scale, Telecare’s wireless glucometer, and Vitality’s GlowCaps device all can find mobile networks when the sensor is triggered and so transmission of clinical data does not require the patient to do anything. (http://ow.ly/3K2FR)

Conclusion

Smartphone technology is already transforming the healthcare industry, but many physician and hospital leaders have not thought through the implications of their widespread adoption by both consumers and physicians. By understanding the implications of smartphones for communication, transactions, knowledge, and integration, leaders can begin to map successful strategies and tactics during a time of delivery system and payment reform. As John Mattison, MD, of Kaiser Permanente states, “The new wellness delivery channel for ubiquitous care will be the smartphone, and it will happen sooner than you think.” (http://ow.ly/3GIwf)

Kent Bottles, MD, is past-Vice President and Chief Medical Officer of Iowa Health System (a $2 billion health care organization with 23 hospitals). He was responsible for the day-to-day operations of a large education and research organization in Michigan prior to his work with in Iowa with IHS. Kent posts frequently at his new blog, Kent Bottles Private Views.