“Now, at any time of day or night, you can demand and get a secure video consultation with a doctor via smartphone at the same cost (about $30-$40) as the typical copay charge through employer health plans. This may seem exotic now, but several large consulting firms—including Deloitte and PricewaterhouseCoopers—have forecast that virtual physician visits (replacing physical office visits) will soon become the norm.”
Beats calling for an appointment, waiting days to see the doctor, then making your 9:00 a.m. appointment days hence only to see the doctor at 11:00, after sitting in a room full of sick and possibly contagious patients, for a brief 5-10 minutes meeting with your harried and stressed doctor, then driving over to the pharmacy to get your prescription, waiting there for 30-45 minutes with retching, sick and possibly contagious Typhoid Marys and having to deal with Miss Grumpy the pharmacy sales clerk, then driving back to work only to hear your supervisor bitch and moan.
By ERIC J. TOPOL
Over the past decade, smartphones have radically changed many aspects of our everyday lives, from banking to shopping to entertainment. Medicine is next. With innovative digital technologies, cloud computing and machine learning, the medicalized smartphone is going to upend every aspect of health care. And the end result will be that you, the patient, are about to take center stage for the first time.
With the smartphone revolution, an increasingly powerful new set of tools—from attachments that can diagnose an ear infection or track heart rhythms to an app that can monitor mental health—can reduce our use of doctors, cut costs, speed up the pace of care and give more power to patients. Digital avatars won’t replace physicians: You will still be seeing doctors, but the relationship will ultimately be radically altered. (I consult for several companies on many of the issues discussed here.)
All of this raises serious issues about hacking and personal privacy that haven’t yet been addressed—and the accuracy of all of these tools needs to be tested. People are also right to worry that the patient-doctor relationship could be eroded, diminishing the human touch in medicine. But the transformation is already under way.
Let’s say you have a rash that you need examined. Today, you can snap a picture of it with your smartphone and download an app to process the image. Within minutes, a dedicated computer algorithm can text you your diagnosis. That message could include next steps, such as recommending a topical ointment or a visit to a dermatologist for further assessment.
Smartphones already can be used to take blood-pressure readings or even do an electrocardiogram. ECG apps have been approved by the U.S. Food and Drug Administration for consumers and validated in many clinical studies. The apps’ data are immediately analyzed, graphed, displayed on-screen updated with new measurements, stored and (at an individual’s discretion) shared. I thought I’d seen it all in my decadeslong practice as a cardiologist, but recently, for the first time, I had an ECG emailed to me by a patient, with the subject line, “I’m in atrial fib, now what do I do?” I immediately knew that the world had changed. The patient’s phone hadn’t just recorded the data; it had interpreted it.
Now, at any time of day or night, you can demand and get a secure video consultation with a doctor via smartphone at the same cost (about $30-$40) as the typical copay charge through employer health plans. This may seem exotic now, but several large consulting firms—including Deloitte and PricewaterhouseCoopers—have forecast that virtual physician visits (replacing physical office visits) will soon become the norm. Deloitte says that as many as one in six doctor visits were already virtual in 2014. In many U.S. cities, you can even use a mobile app to request a doctor’s house call during which a physician would not only provide a consultation but could even perform procedures, such as suturing a wound, which would have usually required an expensive emergency room visit.
With innovative digital technologies, cloud computing and machine learning, the medicalized smartphone is going to upend every aspect of health care. AGENCE FRANCE-PRESSE/GETTY IMAGES
Many surveys show that most consumers want to get information about the actual costs of their care from their doctors but can’t get it. Going forward, what things cost will no longer be the great unmentionable hanging over medicine: Cost-transparency apps for your smartphone already exist and are quickly being expanded to cover lab tests, scans, procedures, hospitals and doctor visits.
Even bigger changes are in the works. Using wearable wireless sensors, you can use your smartphone to generate your own medical data, including measuring your blood-oxygen and glucose levels, blood pressure and heart rhythm. And if you’re worried that your child may have an ear infection, a smartphone attachment will let you perform an easy eardrum exam that can rapidly diagnose the problem without a trip to the pediatrician.
These innovations are just the start. In the next year or two (depending on approval by the FDA), many Americans will probably start sporting wristwatches that continuously and passively capture their blood pressure and vital signs with every heartbeat, without even having to press a start button.
Such wristwatch sensors could do enormous good. By having the equivalent of intensive care unit monitoring on your wrist, hospital rooms—those $4,500-a-night risk zones for serious infections and other complications—can be replaced by our bedrooms. As a result, except for ICUs, operating rooms and emergency rooms, hospitals of the future are likely to be roomless data surveillance centers for remote patient monitoring.
Other wearable sensor tools now being developed include necklaces that can monitor your heart function and check the amount of fluid in your lungs, contact lenses that can track your glucose levels or your eye pressure (to help manage glaucoma), and head bands that can capture your brain waves. Someday, socks and shoes might analyze the human gait to, for instance, tell a Parkinson’s patient whether his or her medications are working or tell a caregiver whether an elderly family member is unsteady and at risk of falling.
We know that our health is highly influenced by our environment, which has been difficult to quantify. But smartphone sensors under development will be able to monitor your exposure to radiation, air pollution or pesticides in foods. And your medications could soon be digitized to provide you with reminders to ensure that you’ve taken them as prescribed.
It isn’t just hospitals’ rooms that are on their way out; so are their labs. Smartphone attachments will soon enable you to perform an array of routine lab tests via your phone. Blood electrolytes; liver, kidney and thyroid function; analysis of breath, sweat and urine—all can be checked with small fluid samples in little labs that plug directly into smartphones. And you can do your own routine labs at a fraction of the current cost.
Smartphone selfies are all the rage, but smartphone physical exams are just taking off. The ability to make a definitive DIY diagnosis of an ear infection with a phone is just the first step. Apps are now being developed to handle all aspects of the eye, the throat and oral cavity, and the lungs and heart. Meanwhile, nearly all sophisticated medical imaging devices are being miniaturized: Hand-held ultrasound devices are already available, and some medical schools have begun issuing them in the place of the old-school stethoscope. Hand-held MRI (magnetic resonance imaging) machines aren’t far behind, and engineers at UCLA have come up with a smartphone-sized device that can generate X-rays. It won’t be long before you can take a smartphone X-ray selfie if you’re worried that you might have broken a bone.
In the next decade, you—under select circumstances, involving high risk or major medical need—will be able to monitor almost every organ system, no matter how difficult to access, as firms start to produce nanosensors to be embedded in your bloodstream. These microscopic sensors within your body can float in blood or be fixed to a microstent in a tiny blood vessel. You’ll then be able to keep your blood under constant surveillance for the first appearance of cancer, autoimmune attacks on vital tissues or the tiny cracks in artery walls that can lead to heart attacks or strokes.
With all these new tools, it is no surprise that we’re talking about the possibility of “doctorless” medicine. Let’s not get too carried away. You’ll still be seeing doctors—but you’ll have a lot more control.
That change is badly overdue. Medicine has long been dominated by a priestly class, beginning with Imhotep, the first physician (and a priest), in Egypt some 4,600 years ago. Things had hardly changed two millennia later when Hippocrates, widely considered the father of medicine, held that most medical information should be concealed from patients.
Hippocrates’s paternalistic sentiments survive today in our culture’s pervasive sense that “doctor knows best.” Physicians obviously tend to think so, but that sentiment is also powerfully reinforced by the top-down way medical information flows (or clogs). The vast majority of doctors are unwilling to email patients or share their office notes. Getting a copy of a report after lab tests or medical scans seems impossible—and don’t even think about getting the results or images themselves. That is all about to change.
We’re often told that the U.S. faces a big looming shortage of physicians. The expansion of DIY medical capabilities certainly challenges that notion: We may end up not having a physician shortage at all.
But one discipline already has an unequivocal dearth of health-care professionals: mental health, which is also the leading cause of disability in the U.S. and many other developed countries. Smartphones can be particularly helpful here. New apps aim to quantify your state of mind by a composite of real-time data: tone and inflection of voice, facial expression, breathing pattern, heart rate, galvanic skin response, blood pressure, even the frequency and content of your emails and texts.
We may soon take an even bigger step forward, thanks to the unexpected advantages of virtual psychiatrists. Recent studies, including a paper by Gale Lucas and others published last year in the Journal of Computers in Human Behavior, have demonstrated that people are more willing to disclose their inner thoughts to a computer avatar or “virtual human” than a real one. With machines working to quantify moods and even offering virtual counseling to help make up for our current profound shortage of mental health professionals, we can glimpse a new approach to improving mental health.
This is heady stuff—but this vision of medicine also raises some serious and reasonable concerns. Before these tools enter widespread use, they must all be validated through clinical trials and shown to not only preserve health but to do so while lowering costs. Without such validation, the whole promise of digital medicine will be for naught.
Moreover, while we may find cases in which it is easier to tell things to a digital avatar, we can’t rely on avatars as doctors, powered by DIY physical exams and lab tests alone. These new high-tech tools can provide useful medical information directly, quickly and inexpensively to consumers. But physical visits with doctors will never be replaced for important, serious matters that require face-to-face conversations—and no keyboards.
Even as we’re making great strides in capturing personal medical information, we’re way behind in dealing with the data deluge. We’ve done far too little to protect our precious personal health data’s privacy, stop it from being sold to third parties or secure it from hacking. We’re also pathetic at data analytics: We tend to hoard big data and have done relatively little to extract meaningful information from it. To make matters even more complicated, none of the new patient-generated data—from sensors, lab tests, self-exams, DNA sequencing or auto-imaging—is flowing into the traditional hospital- or doctor-owned electronic health records.
I think all these problems can be managed, but it will take work. And these obstacles shouldn’t dissuade us from seizing the progress that is at hand.
The real revolution doesn’t come from having your own secure, in-depth medical data warehouse on your smartphone. It comes from the cloud, where we can combine all our individual data.
When that flood of data is properly assembled, integrated and analyzed, it will offer huge new potential at two levels—the individual and the population as a whole. Once all our relevant data are tracked and machine-processed to spot the complex trends and interactions that no one could detect alone, we’ll be able to pre-empt many illnesses.
Take asthma attacks. A teenager who’s prone to wheezing in gym class could get comprehensive data on environmental exposures such as air quality and pollen count, along with data on physical activity, oxygen concentration in the blood, vital signs and chest motion; their lung function can be assessed through their smartphone microphone, and their nitric-oxide levels can be sampled via their breath. Then that information could be combined with the data from every other tracked asthma patient—and trigger a warning, delivered by text or voice message on the teenager’s phone, that an attack is imminent and tell the teenager which inhaler would prevent it.
The same type of procedure could prevent heart failure, seizures, severe depression and autoimmune disease attacks. It could save countless lives.
Finally, we simply cannot imagine what we’ll learn from the brave new world of open medicine: massive online information resources that pull together data from millions and eventually billions of individuals. Think of Facebook’s ability to obtain social data from more than a billion people—but now imagine pulling together medical information never previously aggregated or even acquired. A person who develops a new illness could use an open-medicine resource to find their nearest “neighbor”—the individual who most closely resembles their condition—to help determine the best treatment.
Putting hundreds of sensors into cars and providing exquisite computer navigational support didn’t just produce autonomous cars; it also made them safer than old-school, lower-tech cars driven by humans. The same combination of sensors and computing power is about to do something similar to medicine—transforming it from a weakly evidence-based practice to a data science, with empowered individuals at center stage.
As more medical data is generated by patients and processed by computers, much of medicine’s diagnostic and monitoring aspects will shift away from physicians like me. The “doctorless” patient will remain in charge, turning to doctors chiefly for treatment, guidance, wisdom, experience, empathy and the human touch. These doctors won’t write orders; they’ll offer advice.
Just as the printing press democratized information, the medicalized smartphone will democratize health care. Anywhere you can get a mobile signal, you’ll have new ways to practice data-driven medicine. Patients won’t just be empowered; they’ll be emancipated.
Dr. Topol is a cardiologist and the director of the Scripps Translational Science Institute in La Jolla, Calif. He is the author, most recently, of “The Patient Will See You Now: The Future of Medicine Is in Your Hands,” published by Basic Books. He consults for Google, AT&T, Walgreens, Quanttus and Sotera Wireless on many of the issues discussed and sits on the board of directors of Dexcom