Your own personal pocket doctor

A patient with depression, whose doctor hasn’t found a drug that works, knows the anguish of the long wait. She tries a drug for a week, reports to the doctor, tries longer or changes meds, and reports back again.

Feeling better can take months. What if doctors could land on an effective treatment sooner?

Ayal Schaffer, a professor in the Department of Psychiatry, recently asked himself that question. And, he wondered, what if patients could report on how they were doing, every day, from their homes?

To find out, Schaffer and a departmental colleague, Professor David Kreindler, recruited patients for a novel study. Instead of traditional paper and pencil, patients used cellphones to track symptoms — and report twice a day.

“By day four, we could start to distinguish between those who got better and those who didn’t,” says Kreindler, the interim head of youth psychiatry at Sunnybrook Health Sciences Centre, who has been driving the use of handhelds in psychiatry for the better part of a decade. “With more and better information, we can make better treatment decisions for our patients.”

Kreindler and Schaffer’s work is just one example of how evolving phone technology is radically changing medicine. Known as “mHealth,” smartphones let researchers and physicians track and study disease with new rigour, to treat it with unprecedented timeliness and to invite patients to share in their own care in ways previously unthinkable.

Smartphones today are 30 times faster than they were a decade ago, have 1,000 times the memory and 40 times the image resolution — more than enough to show X-rays and magnetic resonance imaging. Doctors use phones to consult medical literature, and patients can check blood pressure and other health indicators with ease — and get doctor-approved feedback right away. And phones that link wearable medical devices with hospitals for continuous health monitoring and treatment are on the horizon.

“Things are changing in a big way,” says Kevin Imrie, a professor of medicine and Physician-in-Chief at Sunnybrook.

Smartphones are also changing the way doctors and patients relate. Chi-Ming Chow is a professor of medicine, a cardiologist at St. Michael’s Hospital and a former computer scientist. He’s developed several apps that allow doctors to look up complex medical information immediately and give advice to patients quicker. This rapid access, says Chow, is a “seismic shift.”

One of Chow’s first apps was Drive+Fly for the Canadian Cardiovascular Society — which helps doctors and patients remember travel restrictions for people with heart problems. These can be complex, and even doctors can’t always remember them, Chow says. In the past, doctors would print out the guidelines, and then had to find them when needed. “Now, with two clicks you can look up any guideline,” says Chow. Doctors can spend the extra time with patients.

Chow has developed apps for treating atrial fibrillation and heart failure, analyzing lipid levels and prescribing antiplatelet drugs. He’s now working on C-CHANGE, which will harmonize heart related guidelines from eight professional organizations and offer a library of clinical trials that inform the advice. “It’s like an essential Beatles anthology,” he says. And all for free.

Not only are doctors a click away from important health-related information — increasingly, patients are too. Alex Mihailidis and Barry Trentham, professors in the Department of Occupational Science and Occupational Therapy, have developed an app called Age-CAP, which allows people to rate the age-friendliness and accessibility of services from restaurants to crosswalks. “We wanted to have seniors better engaged with their well-being and health,” says Mihailidis, who is also a scientist at the Toronto Rehabilitation Institute at University Health Network.

Because the app relies on crowdsourcing, the more people who use Age-CAP, the more its value grows.
Thanks to websites like Dr. Google, MayoClinic.com and PubMed Health, patients entering the clinic also have more health information than ever before.

At Sunnybrook, an early adopter of mobile technology, Imrie is upbeat about the effects of handhelds on doctor-patient relations.

“I feel interaction has been enriched,” he says. “There’s much more a sense of dialogue.” Imrie shares images, lab results and records through his iPhone and tablet with patients at the bedside. Patients can even sign up for a web portal called MyChart to access files and test results on their own devices. “They feel more in control, like we’re making joint decisions on their health,” he says.

While many doctors welcome that new sense of partnership, medical educators are aware that mobile technology can create challenges for doctor-patient relations. “Younger people often see smartphones as an extension of their brains,” says Sue Glover Takahashi, director of education and research in the Office of Postgraduate Medical Education. But will all patients be comfortable if their doctors spend their limited appointment time staring at handhelds rather than face-to-face? “More education researchers are starting to look at that question,” she says.

Smartphones raise other issues as well. They’re expensive. They open a new channel for breaching patient confidentiality. And infection control is a concern in hospitals, as doctors carry the devices, which are hard to clean, in and out of patients’ rooms and around cities. But the promise of mHealth, especially for young doctors, seems to outweigh these concerns.

More to the point, says Alexander Logan, a professor of medicine and scientist at Mount Sinai Hospital, patients are demanding it. “People want to be kept informed when it comes to their health,” he says.

Logan has studied what happens when patients take their own blood pressure and get timely feedback on it. Recently, he gave patients a Bluetooth-enabled blood pressure monitor and a cellphone, set up to transmit readings securely to a server at Mount Sinai. There, a computer processed the information and sent it back to the patients, along with a short message they could read on their phones.

If the readings were in a healthy range, patients were told to keep up the good work; if blood pressure was low or high, their phones reminded them to follow the lifestyle habits they’d discussed with their doctors. Bad readings spurred more frequent prompts — once a day rather than twice a week — and if those readings persisted, the phones told the patients to contact their doctor. If the levels were dangerous, a category predefined for each patient, the system alerted the doctor directly.

In Logan’s trial of 110 diabetic patients with poorly controlled blood pressure, half of the patients were randomized to cellphone telemonitoring and compared to those who measured their blood pressure at home in the traditional way. He found that without additional doctor visits or more medication, patients with cellphone telemonitoring experienced significant blood pressure reduction — more than half hit the target of below 130/80. Less than a third of the control group reached the target.

“Blood pressure monitoring without feedback is useless,” concludes Logan. “But with it, it’s as good as any potent blood pressure- lowering medication.”

Lorraine Ross, a patient who participated in the study, says self-monitoring has changed the way she lives. She learned, for instance, that eating salt really does affect her blood pressure. She admits that doctors had told her that time and again. “But until you see it yourself,” Ross says, “you’re not aware.”

The study has convinced many people that self-monitoring with feedback is a cost-effective way to improve health. Alex Jadad is a professor in the Department of Anesthesia, scientist at University Health Network and founder of the Centre for Global eHealth Innovation, which designed the system Logan used in his study. Jadad believes that true health is not the absence of illness, but rather the ability to adapt and self-manage when faced with challenges. Self-monitoring systems run on mobile technology make that more feasible, he says.

The Centre is now working with Logan to provide these tools to women with gestational diabetes or Type 2 diabetes, and adults with chronic kidney disease. “It’s going to transform health care,” says Logan. Researchers in the Centre are also looking at whether the same idea will help patients manage heart disease or asthma.

Ultimately, it seems the mHealth revolution is less about the “m” and more about Health. It’s about using technology to let people live a healthy and happy life.

Check out this story and more in the Spring 2013 issue of U of T Medicine Magazine.