By Aaron Stupple, M.D.
As the current social media revolution is being compared to the advent of the printing press, Stupple explores whether health behavior apps could have the impact on public health that clean water, sewer systems and antibiotics have.
Despite an increasingly advanced understanding of disease, roughly half of all deaths in the US are preventable, according to a 2004 JAMA
article. And medical and public health efforts to change individual behavior and lifestyle choice have been of little help, the article said.
If patients would make different choices, there’s no telling what rewards could be reaped—environmentally, politically, economically. It is easy to be glib about behavior change; just because we can describe half of all deaths by a simple phrase doesn’t mean the solution is simple. However, revolutions do happen. The greatest boon to public health came with the advent of public water and sewer systems early last century, followed shortly by the advent of antibiotics. A combination of public choices and medical innovations spurred dramatic shifts in life expectancy and quality. Could the same kind of revolution in behavior and lifestyle happen today?
As social networking becomes enmeshed with most traditional media forms and displayed on all mobile devices, we are in the middle of a revolution in behavior that is being compared to the advent of the printing press or the invention of agriculture. In The Creative Destruction of Medicine, cardiologist Eric Topol cites some compelling numbers—800 million active users of Facebook in 2012, 40% of adults use 7 or more devices to remain connected “in restaurants, in bed, and even in places of worship.” Or, just think about how elevators have become welcome opportunities to catch up with friends, or an obligation to catch up on email. So, revolutions can still happen. The question is, can a revolution in connectedness be made to serve medicine?
In the words of Samuel Shem, connection heals. Certainly, there are great risks to privacy in managing the doctor-patient relationship on Facebook or Twitter, but appropriate safeguards don’t rule out small, discrete, controlled interactions between provider and patient, ultimately widened to include family and friends as sophistication allows.
Studies show that smoking cessation counseling correlates strongly with attempts to quit, but poorly with overall success. The reasons are clear—a doctor visit is a powerful influence on choices for hours to days later, but temptations to smoke or overeat or stop taking a medication are ever present. And your doctor is not. Enter the mobile health app. For the connected age, mobile health apps stand to place the doctor’s message in the hands of patients at the time of choice, providing continual gentle nudges rather than monthly or even yearly commands. But how do we get there from here?
Mobile health apps are nothing new, and 44 million are projected to be downloaded in 2012. However, if they hold such promise, why have they yet to achieve any breakout success? In a traditionally conservative field, and especially among more experienced practitioners, might health apps instead be destined for the same historical trash bin as so many other fad technologies once slated to be the saviors of medicine?
Two reasons to think otherwise are (1) roughly 80% of doctors use mobile devices at work, and (2) more experienced and busier doctors are more likely to adopt novel technologies, so long as they work, says a 2011 paper in the Journal of the Medical Informatics Association
This last point underlines the message of this writing. If apps stand to revolutionize health behavior—that’s not to say that they will, only that they might, and that our stagnation during a communication revolution is sufficient reason to give it a try—and if apps are only adopted when they work, then those with intimate knowledge of the realities of medicine should actively engage in app design.
The promises of innovation in this area are astounding, going beyond simple diet, exercise, and smoking cessation functions. As disease profiles shift from acute to chronic conditions that patients must engage with for the remainder of their lives, there are innumerable places to nudge behavior towards health. Given this breadth of opportunities, and the fact that primary care physicians manage a large and diverse share of both chronic conditions and preventive measures, they are uniquely suited to discover and implement apps for behavior change.
How can we make it easy for docs to engage in app design, especially considering their busy schedules and the fact that such work may be foreign to their conception of medicine? I imagine app design becoming incorporated into residency training programs. The resident clinic could employ programmers to work directly with residents, and when ideas arise during the course of the day, someone could be on hand to consider converting them into apps. Residents could conduct home visits with an aim to discover impediments to adherence not evident in the office. And as clinics shift towards a multidisciplinary, patient-centered medical home model, apps could be created to improve the efficiency of this team-based approach. A simple example could be a digital suggestion box, where anyone affecting patient care, from physician to custodian, can use an app to make a recommendation for improved care delivery.
The Wilson Family Practice Residency in Binghamton, NY, enlists local computer science majors to develop apps as course projects. They’ve made some excellent teaching tools, including an ABG Evaluator
and a Warfarin Guide
. While these efforts are largely the product of one teaching attending, Dr. Joshua Steinberg
, they illustrate the potential for app initiatives baked into the entire residency program.
The diversity at the heart of a multidisciplinary primary care clinic could become a hotbed of health app development, and maybe then we will see a revolution in once stagnant behaviors.
Aaron Stupple, M.D., is an internal medicine resident focusing in primary care at Beth Israel Deaconess Medical Center. He blogs at adjacentpossiblemed.blogspot.com and tweets @astupple.