The transition from brick and mortar to digital medicine will profoundly impact the way clinicians and patients interact — and will likely improve clinical outcomes.
Paul Cerrato and I are excited to finally announce the publication of our 5th book together: The Digital Reconstruction of Healthcare: Transitioning from Brick and Mortar to Virtual Care. In March, we posted the table of contents of the new book. Now that it’s reached the “newsstand,” we wanted to whet readers’ appetite by sharing some additional excerpts.
The logical place to start any discussion on this topic is to explain why digital reconstruction is necessary, which we address in Chapter 1:
Episodic Medical Care Often Falls Short
White coat hypertension, the tendency for patients to only present with elevated blood pressure during a doctor visit, illustrates a problem that permeates the entire healthcare ecosystem. Any sign or symptom that a patient exhibits during an office or clinic visit may not be a true presentation of their underlying condition. Unfortunately, this phenomenon not only affects a person’s blood pressure but other common parameters. White coat hyperglycemia has also been documented. And since psychosocial stress is likely a contributing cause of such white coat reactions, white coat hypercholesterolemia, asthma attacks, and numerous other conditions probably exist as well, all triggered by stress hormones. Conversely, any normal readings during a physical examination or laboratory test do not necessarily mean a patient is in good health.
The common denominator in all these scenarios is episodic care. In such situations, clinicians are making a judgement about a patient’s health status based on cross-sectional data, which can be misleading. But given the financial restraints and incentives that exist in healthcare today, it has been the only viable option — until now. With the emergence of virtual care and remote patient monitoring (RPM), gathering long-term data for many clinical parameters is no longer out of reach. That steady stream of online data can be inserted into predictive analytics algorithms to help locate patients at high risk. Some thought leaders refer to this shift in priorities as the movement from episodic to life-based care.
Such digitally enhanced patient engagement is the future of healthcare. No responsible practitioner would conclude a diabetic patient is in good metabolic control based on a single blood glucose reading, and yet that is often the same reasoning we use when a routine metabolic panel comes back stating LDL cholesterol, serum calcium, white blood count, blood pressure, and numerous other parameters are all “within reference range.” We now have the technology to move beyond this outdated mindset. That technology enables us to detect longitudinal patterns of change in patients’ health status. By way of example: Longitudinal data on systolic blood pressure has been linked to patients’ risk of cardiovascular disease.
The Power of Remote Patient Monitoring
Many patients and healthcare professionals have yet to appreciate the power of remote patient monitoring. When executed correctly, it can be truly transformative, combining medical self-care, objective physiological data, and expert advice to improve both preventive and therapeutic care. And as RPM continues to mature, it has the potential to completely reinvent healthcare, especially among those motivated patients who see it as a source of self-empowerment. The power of RPM in the hands of motivated asthmatic patients was well illustrated in an experiment conducted by University of Wisconsin and Centers for Disease Control and Prevention researchers.
Using an electronic medication sensor that was attached to inhalers of 30 patients, Van Sickle et al. tracked patients’ use of inhaled short-acting bronchodilators for 4 months. To evaluate patients’ health status, investigators asked them to fill out surveys, including the Asthma Control Test (ACT). One month into the study, they also received weekly emails that summed up their medication usage for the preceding week and offered suggestions on how to comply with the National Asthma Education and Prevention Program guidelines. No changes were observed in ACT scores after the first month, but they increased by 1.40 points each month after that. Patients also reported significant decreases in daytime and nighttime symptoms. They also noted “increased awareness and understanding of asthma patterns, level of control, bronchodilator use (timing, location) and triggers, and improved preventive practices.” That last statement is worth closer inspection.
Very often, patients do not understand the triggers that cause symptoms, unless they are actually attuned to subtle changes in their physiology. Providing graphic displays of their symptoms paired with the medication usage can be eye opening for many patients who never noticed patterns of use before. These newfound revelations were summed up by several patients participating in the study:
“I learned that I used my inhaler more than I remember. I was able to see and relate to my doctor that my asthma is not under control.’’ Participants also reported that the receipt of information about the time and location where they used their inhaler helped to highlight locations and exposures to triggers that led to symptoms. ‘‘I’ve been more keen to note surroundings when I feel shortness of breath,’’ one participant said. ‘‘It opened my eyes to triggers I wasn’t aware of in the past.’’
The results of this experiment highlight two important lessons for patients and clinicians, summed up in a few choice words from Kamal Jethwani, MD, MPH, from Partners HealthCare: “The future of health is proactive, self-managed wellness. We want to put the onus back on the person. We’re saying: It’s your health, and I’m no longer your babysitter.”
This piece was written by John Halamka, MD, president, and Paul Cerrato, senior research analyst and communications specialist, Mayo Clinic Platform.