Mobile Health: How Mobile Phones Support Health Care

Last month, Medgadget announced the development of the Magnifi iPhone adapter from start-up Arcturus Labs (Palo Alto, CA), which connects your iPhone 4 or 4S to optical instruments ranging from microscopes to binoculars and telescopes.

To learn more about the evolution of the Magnifi, we spoke with newlyweds Xianne and Isaac Penny who came up with the rough idea for the device while in grad school at Stanford University. They began the development of the product after graduating. Isaac Penny also worked as an engineer at Intuitive Surgical (Sunnyvale, CA), where he helped create the daVinci Single-Site line of instruments.

“Somewhat related to what I was doing for research at Stanford, I was working on medical devices for the developing world,” Isaac Penny says. In the course of that research, he visited a number of clinics in Africa. “A lot of them don’t even have PCs or laptops but they have their cellphones and they were documenting stuff with cell phones, which they would attach to a camera,” he remembers. “Grad students at Stanford do that a lot, too. So we figured maybe other people who use microscopes do as well.”

While the idea was first developed for microscopes, they realized that it would work with other optical instruments such as binoculars and telescopes as well. “Feedback from customers and users that has helped us home in on the product,” Isaac Penny explains.

“There were some unexpected fields where we didn’t see that this would apply to,” Xianne Penny says. For instance, it can be used by optometrists and ophthalmologists because it would fit their slit-lamp microscope. It can also be used by endodontists—dental surgeons who do root canals and use microscopes to look inside the drill hole in teeth to observe what the root looks like from the inside of the tooth.

The device also helps in teaching situations that involve microscopes. With the Magnifi, multiple students can gather around the microscope and view a slide at the same time—instead of taking turns to do so. It also can be used with services such as Skype or Facetime to project images to a projector computer. “You could have a live demo for education in a classroom,” Isaac Penny says.

The functionality of the Magnifi can be further expanded with third-party apps. For instance, apps such as Camera Plus and Camera Awesome enable users to lock the focal length to prevent the potentially annoying autofocus issues. Another app known as Eye Microscope can be used to add scale bars, date and magnification to images taken with the phone.

The device works on eye pieces in the range of 1 to 1.5 inches in diameter. It must also be able to slide over the eyepiece at least 1 inch without obstruction, so that the camera’s optics can get close enough to align.

Arcturus Labs is planning on coming out with another adapter to enable Magnifi to be used for an even wider range of optical instruments, namely spotting scopes and other optics with large diameter eyepieces. The new adapter will be interchangeable with current Magnifi case and future cases within the product line.

Link: Arcturus Labs…

For at least the last 50 years, different to other industries, technological advancements in medicine have increased, rather than decreased costs. This has occurred for reasons whose analysis is outside the purpose of this paper. It’s sufficient, therefore, to note the truth of it and move on.

Recent developments in mobile health technology, known as “mHealth” to its adherents, give us hope that perhaps the technological tide is finally turning. It is our hope that these trends will cause tech to improve care (which it has always done) and drive down costs.

What gives us this hope? First, let’s examine a few interesting statistics. A recent Information Week article stated that 70% of polled hospitals and/or healthcare organizations plan to deploy the iPad by the end of 2012. This matches with market research that indicates that some 81% of physicians will own a smart phone or tablet by the end of 2012. Of those, move than 50% will use mHealth apps daily in 2012. Globally, it is predicted 500 million people will be using mobile healthcare applications by 2015. We think these estimates are low. The proliferation of iPads and iPhones among healthcare personnel literally makes these devices a Trojan Horse into GE- and Phillips-dominated healthcare.

All of these numbers are signs of a sort of sea change that is affecting not just the healthcare industry, but also the world. Competition has driven down the overall costs of these powerful pocket computers (tablets and smartphones) to the point that they are becoming as ubiquitous as simple cell phones were just 5 years ago.

We should point out that part of the reason this excites us is not just for the potential to reduce costs in the United States, but because of the ability of mHealth to improve care and outcomes in developing nations. These countries have neither the time, nor the resources, to build the healthcare infrastructure developed over the last 60 years in the industrialized world.

New innovators and existing players will be drawn to use these mobile platforms to come up with solutions because of the opportunity to do good, of course, but also because of new market possibilities. Predictions on the size of the mHealth market vary, but most put it anywhere between $5 and $35 billion dollars.

What will our mHealth future look like? While it’s tough to say, exactly, we can make a few educated guesses based on where companies (like those being shepherded by the promising Rock Health incubator) are developing now. By and large, they’re developing products and services that incorporate most of the following characteristics.

The user interface is visually interactive and engaging. Nothing highlights the importance of this point more than the rise of Pinterest.They have the ability to access best-practice and neutral information that is based on sound science, anytime and anywhere. It’s a mobile world.The information being provided is personalized and adapts to the uniqueness of each person’s condition.They are able to make real-time use of feedback loops. The article that brought this home for us was “Harnessing the Power of Feedback Loops” by Thomas Goetz in Wired July 2011.So-called ‘gamification’ of products and services is used appropriately. These efforts will continue to blur the line of reality—therein lies their power.Secure and trustworthy use of utility and monitoring. This is made possible on a large scale by the rise of cloud computing.Everything is social and sharable (to the extent that they want to be social and share about their health). This means they are able to engage, discuss, research, and respond to one another with up-to-date information, experience, and support.Use of geo-location. Here, again, the importance of mobile and all that goes along with it from apps and web apps (read: HTML5) to mobile-optimized websites.Price comparison: In concert with geo-location, health consumers will be able to ‘shop’ for the best, least expensive medical product/service.

While it’s difficult to say exactly what healthcare will look like and how it will develop in the next few years, these are the early signs of what we believe will be an mHealth future which drives down costs and improves outcomes for everyone on a global scale.

One medical app subspecialty which has succeeded particularly well since the introduction of mobile technology is differential diagnosis support. Apps that make sure you don’t miss a crucial diagnosis are popular on the wards and for good reason. One which was particularly well is Diagnsosaurus which we reviewed the iPhone version of back in 2009 and loved it.

In that article we listed the positive and negative qualities that we found with the app.

Now let’s take a look at its cousin on the Android.

Diagnosaurus DDx from Unbound Medicine is a medical app that helps you formulate differential diagnoses based on either signs and symptoms or clinical findings.

This app is not meant to make the diagnosis for you, but rather assist you in reaching a diagnosis and guide further work-up.

From the first time I used this app on my old iPhone 3G to now using the Android version, not much has changed. The Android app still has the same familiar interface with the same core structure that also mirrors its website counterpart on Access Medicine.

The only major difference you may notice on the Android version is the different (and nicer) fonts and the increased screen space. This is due to the elimination of the tool bar on the bottom thanks to Android’s dedicated menu and search buttons. With the extra space, the content is much more readable with less need for scrolling. When searching, Google’s speech recognition replaces Apple’s but, not surprisingly, still fails miserably with medical terminology.

Diagnosaurus DDx, like other apps from Unbound Medicine, is clean and minimalistic. You won’t be impressed by any innovative design or illustration element. Other than the title screen and the app icon, no other images are included in this medical app. That’s okay, though, since the emphasis is on the content. The whole app is completely text based and all data is stored on the phone. Not only does this mean no internet access is required when using this app, but also means an almost guaranteed no lag experience with instantaneous reaction times.

Clinical Use:

Although Diagnosaurus DDx is divided into 3 main categories, in the end, I found myself using the search function most of the time, rather than browsing through its endless lists of diseases and symptoms. Some pretty cool examples that I have discovered on this app are differentials for “EKG: long QT”, “loud P2″, and “hypercalcemia”. Almost any clinical situation that I could think of I found on this app. The only instance when the differentials were unhelpful and too broad was under “Fever”, but that is probably my own fault for looking up such a nonspecific symptom.

I have been using Diagnosaurus DDx since the beginning of my clinical rotations as a medical student, and I have definitely benefited from its quick differentials on my “H&P’s and progress notes and during teaching rounds and pimping sessions. Diagnosaurus DDx had also been a helpful study tool for my shelf exams and USMLE Steps. 3 years later, I still find this app to be one of the best medical apps on the market and an irreplaceable part of my smartphone arsenal. If not obvious enough already, I absolutely love this app.

I have been following closely the debate surrounding the FDA's call to regulate apps like you use on your smart phone as a device, like a heart monitor or diabetes test kit.

Is this the right thing to do?

I am all for regulation of industries to ensure safety and make sure no one dies because a product was used. But this is a whole new era. Is an app a device? Is it a life-saving tool or is it the new shiny toy on your smart phone about which you know nothing about the reliability or specificity of how it works? This debate has been roiling the device/app/regulated industry market for a long time already, but is really heating up this week due to pending legislation currently being “worked up” in the U.S. House of Representatives.

There are many legitimate questions at stake. Capitalism and how it relates to government regulated industries in a rapidly changing world for one. Health and safety of any “tool” whether device, software, hardware, application or just a bandaid; when it comes to being used on humans? Should the government stifle innovation efforts by regulating apps for your smart phone exactly as a medical device? Are small companies who are the primary developers of most apps still – being shut out of a marketplace controlled by only the largest and most set in place corporations and being assisted through legislative and regulatory ruling? What happens when one of these apps is used in a “cloak operation” and is actually something like a private information/financial information thief?

Wait, what did I just say? The harsh reality is the FDA even admits that the “device approval” is one of the hardest processes they put any company through, outside of actual drug approval. Just ask any device manufacturer about their recent run-ins with the PMA (premarket approval). You will get an earful.

But translate this to medical smart phone apps and the FDA. Who builds apps? As stated above, mostly small companies with small numbers of employees (obviously there are clear exceptions.) If the apps are to be regulated exactly as devices then it subjects these companies to lengthy, even multi-year engagements just to get approval prior to selling anything. This flips the market dynamics of most app companies; that are used to making their money off short development/lead time cycles, and short sales cycles. How can most small companies survive this? They can’t; and back to the question of a stifling of innovation in small businesses through the FDA on behalf of the few companies with the bucks to last out this process.

I would suggest the FDA look at how software and hardware is approved under FIPS for example. (FIPS are requirements issued by the National Institute of Standards and Technology that apply to federal government computer systems.) Additionally I would suggest the FDA create a tiered regulatory system, one for devices; one for aps. Clearly this debate is not going away without a fight.

GENERAL practitioners will be required to participate in the electronic health records system due to launch on July 1 or lose an existing incentives package worth up to $50,000 a year per practice.