Research on the Value of Mobile Health: An Expert at Scripps Looks Forward
Steven Steinhubl, M.D. is director of digital medicine at the Scripps Translational Science Institute, and a practicing cardiologist at the integrated Scripps Health system, both in San Diego. Dr. Steinhubl joined the Scripps organization in July 2013, after having served as director of cardiovascular wellness and medicine at the Danville, Pa.-based Geisinger Health.
At the Scripps organization, Steinhubl is helping to lead clinical transformation through the adoption of mobile health technologies and through helping to manage clinical trials of mobile health technology. He will be giving the closing presentation, entitled “Medicine Unplugged: Bringing the Solution to the Problem through Mobile Health,” at the upcoming Health IT Summit to be held January 21-22 in San Diego, sponsored by the Institute for Health Technology Transformation (iHT2). The Institute became a part of Vendome Group, LLC, Healthcare Informatics’ parent company, in December 2013. Steinhubl spoke recently with HCI Editor-in-Chief Mark Hagland about the mobile health-related innovations taking place at the Scripps organization, and their implications for the healthcare more broadly. Below are excerpts from that interview.
At Geisinger, you spent 60 percent of your time as a practicing cardiologist, but now, you’re spending only 10 percent of your time in clinical practice, while devoting the rest of your time to this transformational work. Do you find equal satisfaction in clinical practice and in transformational and technology-related work?
Most people enter medicine because they want to help people, and for many, that is fulfilled through direct patient care. But I’ve also always felt a certain satisfaction in being a clinical researcher for 20 years, and I’ve always felt satisfaction in knowing that what I was doing in research might help many people. And so as satisfying as direct patient care is, developing research trials, especially in digital medicine, is also very satisfying. And I believe we desperately need to change how we deliver medicine.
Steven Steinhubl, M.D.
So what are you and your colleagues doing at Scripps?
Scripps Translational Science Institute sits between Scripps Health and Scripps Research Institute, which conducts basic science research. It’s actually one of the most successful non-university-based research institutes in the world. It does a lot of work on genomics, but also on general science. Now, Scripps Translational Science Institute, which was established seven years ago, initially focused on genomic medicine, but then very quickly, because of the atmosphere in San Diego with QualComm and a large number of science/technology companies, quickly shifted over to work in mobile health.
And within that, what are you and your colleagues working on?
Pretty much everything. With regard to the clinical trials we’re running, one-third are specific to a device requiring clinical data primarily for regulatory purposes; and another two-thirds of trials involve payers looking for technology solutions. One great example of a trial we want to do soon is a continuous blood pressure measurement watch. Right now, we get these little snapshots of blood pressure when you go into the doctor’s office; or more rarely, via monitors. But now we’ll know what happens over periods of time. So a lot of the studies we’re doing are to look at brand-new data that will help us understand our individual differences, and how we respond to different stimuli on a moment-to-moment basis.
How many trials are being facilitated right now at Scripps Translational Science Institute?
Five trials are going on right now, and roughly 15 trials are in some sort of planning stages through July 1. And last July 1, we had no trials running. And then, Scripps Health in and of itself is also focused on digital medicine; so I have a role within the Scripps system, beyond clinical trials, of helping to establish Scripps Health as a leader in the adoption of mobile health technologies.
Tell me a little bit about that.
We have amazing technology in the mobile health world, incredible tools we wouldn’t’ have dreamed of having ten years ago. But we don’t know how to fit those into the practice of medicine, and too often, we try to fit them in incrementally. And that really doesn’t work well, because our systems for the most part are not set up to take full advantage of technologies. And I like the phrase that my former CEO at Geisinger used to use, which was “very perverse financial incentives in healthcare.” For example, the most common diagnosis coming out of a patient visit to a doctor is high blood pressure; but most of those visits could be eliminated if you had the right monitoring technology that could be automatically relayed to EHRs [electronic health records]. And despite the fact that 50 percent of heart attacks and 75 percent of strokes are related to hypertension, we aren’t getting things evaluated and managed in a timely way, in terms of getting patients in at the right time, and making the right interventions.
So there’s this lack of synchronicity—there are asynchronous appointments for doctor visits, and so on; so most of healthcare hasn’t really been designed around the patient, to make sure their blood pressure, lipids, diabetes, are well-controlled. And it’s not that anyone is trying to do anything poorly, but rather, that the system is designed to keep people coming into see providers. And the mobile technology paradigm is the opposite: the idea is that the technology needs to be designed to help manage patients more effectively. And Scripps Health is focused on that.
That is very similar to what Dr. Dave Levin, the CMIO of Cleveland Clinic, has been saying publicly, including in his new book.
Yes, I just met him last year, and I trained at the Cleveland Clinic, so I’m very much on the same wavelength as Dr. Levin and his colleagues.
We’re at a fascinating inflection point now in healthcare, with regard to a confluence of factors, including reimbursement reform- and technology-driven changes. What do provider leaders need to do, then?
It’s a great challenge, because in most places, provider leaders are torn, because any place that is still making money from fee-for-service medicine has to straddle needing to still make money paying the bills, while understanding that the fee-for-service payment system is going away eventually. So readers have to be able to look to opportunities to do both at the same time, but at the same time be very cognizant that things are changing quickly. There’s so much room for change in healthcare, and the true leaders are going to say, OK, from the ground up, I’m going to completely rethink healthcare. And the sensors we have today only represent a small proportion of the tools we’ll have in just a few years. It’s amazing how rapidly this personalized technology has advanced. And so the true visionary has to recognize that our capability to diagnose at home and the corner drugstore, is going to be reality. And then they have to recognize how to redesign healthcare delivery to meet that emerging reality.
So you’re a radical, then—in a good sense!
Yes, but it’s taken me a while to get there. I was an engineer before I went to medical school; and I went into medical school after working for Eastman Kodak. And I kind of went into medicine with that same mentality that healthcare should be more of an altruistic endeavor, and less of a business. Healthcare is the most unbelievable job in the world—you get paid and paid well to help people feel better and even to save lives. But the payment system has kind of ruined that—the payment system, and the systems designed to respond to that payment system. And when you do attitudinal surveys of physicians, you find that physicians are demoralized, and two-thirds would never encourage their children to become physicians. And to me, that’s depressing in that many doctors feel that some of the most satisfying aspects of medicine have disappeared.
A lot of physicians are getting stuck in the reimbursement rut now, and obsessing about maintaining their current compensation levels. How do you convince them to embrace the emerging world of technology-facilitated care management?
I think that’s a problem that begins back in medical school, where you’re paying unbelievable amounts of tuition, and creeps into physicians’ decision-making patterns in their current practices. The reality is that, as a cardiologist, the more nuclear stress tests as opposed to regular stress tests that you do, the more money you’ve got. And it’s very easy to recommend that nuclear stress test, despite the radiation risk and the potential for false positives. So we’ve developed this system where it’s very dependent on physicians making non-self-serving decisions, but with the financial pressures on physicians, too often, I’ve seen physicians making decisions based on what’s justifiable rather than on what’s right.
So how do CIOs and CMIOs help to facilitate mobile health adoption in their organizations in a strategic way now?
To be successful, it has to be incorporated into current care. For primary care doctors to really do everything they’re supposed to do, with a normal mix of chronically ill patients, and in terms of the established clinical guidelines, across a typical panel of 2,000 patients—to do the kind of care management they should be doing—would take 22 hours a day. So the first thing is that CIOs and CMIOs have to be aware of that. I loved Geisinger as a place to work, but I would often find that the innovation leaders there would say, OK, we’ll just ask physicians to do this one thing, and it’ll take just an extra 15 seconds; but that still added a burden, and it felt like an imposition [to practicing physicians]. So to be successful in adopting mobile health, you need to do it collaboratively.
In that regard, I’m a big believer in doing small-scale pilots, so, for example, in one clinic, we’ll do all our diabetic care management using automation, but understanding that this clinic will likely not be as successful financially for one year, and we’ll take the hit financially in order to gain the experience, knowing that will be the future of care. But if you’re designing a clinic so that for example, you shift blood pressure or glucose monitoring, to non-physicians, the direction has to be top-down and yet executed in a collaborative way involving all those who might be impacted.
What will happen in the next couple of years among the more advanced patient care organizations?
I think for the first time, we’ll start to see some truly mobile health-managed patients, in a Kaiser, let’s say, that will say, that will provide insights as to how such initiatives have worked. And hopefully we’ll see that at Scripps, too. The thing is, we don’t have true clinical trial-level evidence for the value of mobile health. We think the value is there, but we don’t have the data yet; indeed, most of the data around mobile health has been in very small pilots. So we’ll start seeing some smaller clinical trials, and eventually, larger trials, in this area.
Is it actually necessary to prove to people statistically the value of mobile health?
I understand your question. Let’s look at something like a watch that would continually monitor your glucose; the assumption would be that that would help. But actually, with regard to diabetic patients who do daily finger-stick testing, it’s been found that the outcomes coming out of continuous monitoring have in fact been associated with increased anxiety levels among those patients.
And we don’t know exactly why, but these were people who did finger sticks anyway, so it presumably wasn’t the anxiety over doing finger sticks, but rather, the anxiety over thinking about your glucose level all the time. I remember speaking with a patient who said, people like me don’t like being constantly reminded of our chronic condition. And there is the potential in this of reminding people 24/7 of their chronic illness.
So we could ask the question, will such an intervention actually improve clinical outcomes? Some things don’t require clinical trial work, but some could use it. We’re doing a trial on PTSD and monitoring people 24 hours a day, and we’ll find out interesting things there. And then, does measuring your blood pressure at home once a day, versus coming into your doctor’s office? That probably doesn’t need to be trialed except with regard to cost savings.
That was trialed at Kaiser. And also, Kaiser did a nice study that showed that home blood pressure monitoring was actually no better than doctor blood pressure monitoring, unless you also included more intensive interventions, such as through pharmacists. Just giving someone a home monitor made no difference, but if you included people-based care management, it made a marked difference, since now there was an individual associated with that device, and it was the connectivity made all the difference.
Are you optimistic about the forward evolution in this area?
I’m very optimistic, yes. I mean, I think it will be a painful example. Two weeks ago, South Korean doctors were ready to go on strike over mobile health; they saw in it a potential for causing them to lose their jobs. So in the short and medium term, there will be a lot of challenges; you have a lot of tech jobs, and even physician jobs—a healthcare system, really—designed around fee-for-service reimbursement. So we need to look at the financial incentivization involved; but if we focus on what’s best for patients, it will ultimately work out for patients in the health care system.
