Virtual health care will revolutionize the industry, if we let it - Harry Wang
image by: Adirondack Health Institute
Will “virtual medicine” transform the American health-care system? Will the latest computer-based technologies—apps, wearables, remote monitors and other high-tech devices—make Americans healthier? That’s the promise made by tech gurus, who see a future in which doctors and patients alike track health problems in real time, monitor changing conditions and ensure both healthy habits and compliance with drug and therapy regimens.
If it all sounds too good to be true, that’s because it is. Computer-enabled technology will indeed change the practice of medicine, but it will augment traditional care, not catalyze the medical revolution prophesied by Silicon Valley. Machine learning will replace radiologists and pathologists, interpreting billions of digital X-rays, CT and MRI scans and identifying abnormalities in pathology slides more reliably than humans. Remote observation of patients will be used in tele-intensive care units. And monitoring technologies will make it easier to treat patients at home, facilitating more out-of-hospital care.
But none of this will have much of an effect on the big and unsolved challenge for American medicine: how to change the behavior of patients. According to the Centers for Disease Control and Prevention, fully 86% of all health care spending in the U.S. is for patients with chronic illness—emphysema, arthritis and the like. How are we to make real inroads against these problems? Patients must do far more to monitor their diseases, take their medications consistently and engage with their primary-care physicians and nurses. In the longer term, we need to lower the number of Americans who suffer from these diseases by getting them to change their habits and eat healthier diets, exercise more and avoid smoking.
There is no reason to think that virtual medicine will succeed in inducing most patients to cooperate more with their own care, no matter how ingenious the latest gizmos. Many studies that have tried some high-tech intervention to improve patients’ health have failed.
Consider the problem of patients who do not take their medication properly, leading to higher rates of complications, hospitalization and even mortality. Researchers at Harvard, in collaboration with CVS, published a study in JAMA Internal Medicine in May comparing different low-cost devices for encouraging patients to take their medication as prescribed. The more than 50,000 participants were randomly assigned to one of three options: high-tech pill bottles with digital timer caps, pillboxes with daily compartments or standard plastic pillboxes. The high-tech pill bottles did nothing to increase compliance.
Other efforts have produced similar failures. Researchers from the University of California conducted a test involving nearly 1,500 patients with congestive heart failure who were discharged from the hospital. Half were given randomized high-tech interventions, including wireless scales to track weight gain or loss, wireless blood pressure cuffs and digital symptom-monitoring devices. The devices reported back to a central office where nurses monitored the data and followed protocols to call patients who, when appropriate, “were encouraged to contact their health professionals.”
The results, published in JAMA Internal Medicine in March 2016, showed that wireless monitoring and coaching phone calls made no difference compared with conventional care. Within six months, about half the “high-tech” patients were rehospitalized, and they died at the same rate as for patients in the control group. Both groups continued to exhibit high levels of noncompliance with physicians’ orders.
High-tech interventions also have failed to encourage people to live more healthily. For an October 2016 paper in the journal Lancet, researchers at the Duke-NUS Medical School in Singapore randomly assigned employees from 13 organizations to one of four groups, in an effort to encourage exercise. One group got Fitbit Zip trackers, two other groups got the tracker plus money that they could use, respectively, for themselves or for charity, and the last group got no tracker.
The study found that the device increased moderate-to-vigorous activity by 20 to 30 minutes a week after the first six months—but only when cash or charity incentives were in play. When the incentives were discontinued, physical activity returned to pre-intervention levels.
Why is virtual medicine falling short of the techno-optimists’ expectations? Most medicine isn’t about closely monitoring every passing physiological change. Except for patients in the ICU, moment-to-moment numbers on blood pressure, weight or heart rate often don’t really matter. After all, people don’t become obese by overeating for one meal or go into heart failure from one extra-large sugary soft drink. And with the exception of insulin and drugs administered intravenously in the hospital, most medications work over 12- or 24-hour cycles, so the continuous monitoring promised by technology is largely a waste.
Another reason to be skeptical about virtual medicine is the age group in which we most need behavior to change: older patients with chronic illnesses. Many of them may use smartphones, but they are not on the whole adept with high-tech gadgets. Even younger, more tech-savvy patients don’t seem to respond well. A study at the University of Pittsburgh, published in JAMA in September 2016, found that having overweight and obese millennials (ages 18 to 35) wear a multisensory device did nothing to improve their weight loss over 24 months, as compared with the control group.
Technology is certainly great at aggregating data and turning it into useful information, but a lack of data isn’t the main barrier to delivering high-quality, low-cost care. The real challenge lies in changing patients’ habits and behaviors once a health problem is identified.
As behavioral economics reminds us, information alone doesn’t change behavior. Smokers know that smoking is bad for them and that they should quit. Obese people know that they should lose weight. People want to take their medicines and do their rehabilitation exercises. But all of this requires altering habits and daily routines, which is supremely difficult. Think about how little time it takes most people to fail at their New Year’s resolutions.
The only interventions that seem to change the behavior of patients in a lasting way are financial incentives (mainly to stop smoking) and long-term, face-to-face relationships with nurses and health-care coordinators. These interventions are decidedly not high-tech. They are high-touch, and they remain our most effective prescriptions to treat chronic illnesses.
Source: Ezekiel J. Emanuel, The Hype of Virtual Medicine, The Wall Street Journal, November 10, 2017.