mHealth: When Physicians Aren’t Fans

Posted on June 15, 2012 by

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(by andyde at flickr)

“Despite demand and the obvious potential benefits of mHealth, rapid  adoption is not occurring.” ~ David Levy, MD, Global Healthcare Leader

mHealth is a confluence of a number of my middle daughter’s great loves.

  • She adores her iPhone so much that she sleeps with it.
  • Always a visual learner, she’s a total sucker for a chart or graphic. She’s such an infographic fiend that I believe she’s sent me about every one there is to find on this monstrosity we call the world wide web, including–and I really couldn’t make this up–one about what your excretory products tell you about your body. (But that’s just my refined way of  putting it; the infographic refers to them as ‘poop’ and ‘pee.’ I’ve linked you to it–go on, take a look, you know you’re curious.)
  • As she well knows, she’s got a tendency to kvetch, so symptom tracking is great fun for her, since everyone else is tired of hearing about her headache that’s a ’5′ or maybe a ’6,’ at the same time as she informs us all of her nausea that’s creeping into the ’7′ realm.
  • She loves causality, so when her iHeadache (an excellent app) proved that Grandma Susie’s visits caused migraines, she was pleased as punch–both to have been right, and to assert her claim that her other siblings should shoulder a bigger burden of Grandma-time.
  • And she takes a lot of meds, so apps really do make it simpler to know what she’s taken and when, and what the effects of the said drug might be. She was having difficulties with her anti-seizure medication, and was absolutely thrilled with the graph she created below, visually correlating her nausea with her Tegretol (ready for fireworks?):

Of course by the time she produced this work of art, everyone and their brother knew that she vomited when she took Tegretol, so it was somewhat less illuminating than one might have hoped, but nevertheless she presented it as a work of art.

Now, at some point it began to occur to me to wonder why I was so privileged as to be privy to graph after graph and chart afer chart.

And then a truth occurred to me, which applies not just to my daughter, but to many patients: Her physicians, excellent as they are, were simply not interested in viewing her riveting display of charts and graphics (not just the piece about Grandma Susie, but about the side effects, too), and weren’t particularly receptive to to the details of her symptom-monitoring.

Even though part of mHealth is transferring data collections to doctors seamlessly, it’s honestly not something that the majority of doctors are up to speed on.

A PricewaterhouseCoopers (PwC) LLP groundbreaking report, Emerging mHealth: Paths For Growth addresses this issue–along with many significant other ones connected to mHealth.

As the study notes, Professor Chris Taylor, director of University of Manchester’s mHealth Innovation Centre, believes that patients lack follow-through on particular health apps because the information means nothing without a doctor’s interest and investment in it. He observes,

Healthcare professionals don’t currently treat as credible any data that are created [from lifestyle apps].

 Looks like I’ll be viewing headache and menstrual charts for a number of years to come, in lieu of a paid professional.

My daughter has reasonably good medical care, but she’s far from alone in feeling un-attended to by her doctor at times.

In two international studies by SSI* and The Research Intelligence Group (TRiG)*, a full two-thirds of patients around the world felt ‘disrespected by their physicians.’  The main complaint was ‘unclear communication’ (which I believe is challenged by your shivering in a piece of paper as the doctor talks to you while listening to your chest at the very same time).

One-fourth of surveyed patients

complain that physicians don’t answer questions, don’t involve them in treatment decisions and use medical terms with no explanation.  This appears to be a direct outcome of doctors not spending enough time with patients (44%). . . . [O]nly a quarter of patients are happy with their involvement in treatment decisions.  Almost half of patients around the world (46%) say that they would be more satisfied if physicians would explain the treatment process and possible side effects in more detail.

[*TRiG's was an online study of 22,581 adults in 23 countries executed through the World Independent Network of Market Research (WIN™). SSI's online study of over 5,000 adults was designed to determine the reasons behind the TRiG findings. See "Patients Around the World are Not Happy with Their Physicians, Feeling Disrespected, Hurried through Visits and Shut out of Treatment Decisions."]

That level of concern and dissatisfaction with physicians’ role in medical care may very well help explain the following graph, depicting just U.S. interests, but representative of what is going on globally:

As they say, ‘Follow the money.’ The graph points out a known truth: Patients are finding–or hoping to find–in mobile health applications what they can’t fully find in their doctors’ offices.

It’s clear that patients have high hope for mHealth.*

(see Royal Tropic Institute’s “What is mHealth”"-click-through)

[*According to the National Institute of Health, mHealth is: the "use of mobile and wireless devices to improve health outcomes, healthcare services, and health research. See the chart on the side for application areas.]

48% of  respondents in  the PwC report expect mHealth to change, within the next three years “How my healthcare providers and I communicate,” and 48% of people “‘think mHelath applications/services will improve the quality of health care I get.”

But as we’ve seen, a number of doctors are significantly more ambivalent about jumping on the mHealth bandwagon. The PwC’s study’s numbers were rather shocking. The study found that:

Only 27% [of physicians] encourage patients to use mHealth apps in order to become more active in managing their health; 13% actively discourage it.

Chris Wasden, global healthcare innovation leader at PwC, says of the company’s findings:

The study shows that consumers are demanding it, payers are increasingly willing to pay for it, and physicians are resisting it. [emphasis mine]

So, looks like, generally, they might not be the biggest fans.

Which begs the question:  what might be physicians’ concerns about mHealth?

It doesn’t seem to be a fear of the technology.

An impressive 80% of doctors said that they themselves  use smartphones and medical apps. And they are 250% more likely to own a tablet than other consumers.

What’s the holdup?

I think there are a number of complex issues leading to some foot-dragging on doctors’ parts, but I’d like to address two (or two and a smidgen) large concerns: Worry about maintaining physician authority, and  apprehension about how patients make use of online information and the consequent de-professionalization of medicine.

Concerns About Physician Authority

It appears that one of the main concerns among physicians is that mHealth alters the old ‘take 2 tablets and call me in the morning’ hierarchy between doctor and patient.

Certainly mHealth does impart a more ‘take-charge’ role to the patient.Writes  Yael Harris,  PhD, MHS, in “Exploring the Value of Mobile Health,”

What  makes mobile health truly transformative, however, is its ability to actively  engage patients in their healthcare. . . .[It] help[s] the patient take control of his or her healthcare by becoming an  active participant in identifying and seeking appropriate and timely medical  services.

Sounds innocuous enough, even–some might say, well. . . positive.

But  patients  taking the initiative “stands on its head the tradition in which a doctor gives orders and the patient obeys,” according to the New York Times. “And that makes some doctors nervous.”

In point of fact, the PwC piece found that 44% of the physicians surveyed  worry that mHealth will make their patients too independent.

Surprisingly, in the opposite of what we have come to expect from a generational divide in technology, 53% of young doctors (those with five years experience or less) had the same concern.

Dr. Eric Topol, vice chairman of West Wireless Health Institute who also works at the Scripps Research Institute, asserts that mHealth will change doctors’ approaches to their patients, just as some physicians worry. His belief, though, is that this will only be for the better.

“Instead of doctor-knows-best and this paternalistic type of thing – that is on the way out. Doctors have to acknowledge that. . .Still we have this stuck medical establishment – and I am part of that – which is unwilling to democratize medicine. And that can’t go on any further.” [See  "Medical mobile apps to play larger role in patients' health--if doctors let them."]

Of course a significant number of doctors have indeed adopted certain mHealth practice, although it’s notable that they often seem to be some of the more antiquated services.  For example, 38% of doctors currently offer telephone-based consultations, which certainly improves patient access overall. That number drops to 16%, however, for the more technologically advanced use of text-based consultations.

And in a return to the issue of control, a mere 17% provide patients access to parts of their medical record, and a paltry 13% utilize general health and wellness data gathered by the patient’s mobile device  for analysis–so my daughter’s in good company, at least.

Concerns About Unlimited Use of Online Information Sources and Deprofessionalization of Medicine

Then has been, in my lifetime, a deprofesionalization of medicine. I might suggest that it started when doctors’ salaries shrunk below those of management consultants and investment bankers.  Managed care did its part. It continues with mobile health.

The mere fact that patients now have instant and easy access to online information about all aspects of their health alters the old dynamic between doctor and patient for good. In the paper “The doctor, the patient and the world-wide web: how the internet is  changing healthcare,” lead author Powell, from Health Services Research Unit, Department of Public Health & Policy, at the London School of Hygiene & Tropical Medicine, observes of the Internet that it

. . .change[s] the balance of knowledge between healthcare professionals and the public, empowering patients to become more involved in healthcare decision-making and contributing to the deprofessionalization of medicine. The professional power of medicine is being challenged by the public availability of specialist knowledge, and by improved access to information on alternative approaches to healthcare, healthcare performance statistics, and consumer rights.  

Beyond that, while doctors may urge caution about use of online research because they very accurately perceive the cesspool of misinformation that is on there, nevertheless there are well-known sites that provide accurate, timely medical information, and allow the patient to know more about their condition than a short visit to the doctor would allow. Sites like

do put significant amounts of quality healthcare knowledge at the patient’s fingertips, and mobile access makes it accessible at any time–in the grocery store, while waiting in line at the bank, while sitting and stewing her chronically late gynecologist’s office.

And it goes beyond general medical information. Patients have access to the Medscape App on their iPhones, where (talk about deprofessionalizing doctors!) they can access drug reference texts (I particularly like the dosing information for vitamins), check drug interactions (I see here that Paxil has a serious interaction with Coumadin, something I never knew), search a disease and condition reference (here’s an overview, workup and treatment and management plan for salivary gland tumors, major, benign), follow step-by-step instructions for procedures (for real–I’m looking right now at the overview, preparation, technique, and post-procedural information for an appendectomy), access medical directories (apparently there are 25 addictions specialists within my zip code), find screening references–and calculate them (why, here’s a depression screening by a two item PHQ-2)–and I’m just getting started. And–to add insult to doctor injury–it’s free.

Interestingly enough, despite offerings like those above,  overall, doctors still tend to view patients’ bringing information from online sources into appointments somewhat negatively.

In the paper, “Health and the Internet—changing boundaries in primary care,” the researchers studied how often Internet information [which has now become interchangeable with healthcare apps and mobile access] was presented in primary care consultations and the subsequent reactions of the physicians involved.

They found that doctors had more patience with patients with an already-established diagnosis who were using the Internet to find ways to manage their symptoms. However, in other cases,

 Internet users were seen as ‘demanding’. Patients using information from the Internet to self-diagnose and to identify appropriate treatments in advance of consultations  were viewed particularly unfavourably by all health professionals.

A fascinating study, “Survey of Doctors’ Experience of Patients Using the Internet,” concluded that doctors saw patient use of the Internet as beneficial overall to the patients–but not beneficial for themselves.

When asked about patients’ experiences with the Internet, 50% of physicians did not report any problems, 29% reported 2 or more problems, 27% did not report any benefits for their patients–but 51% reported 2 or more benefits.

The numbers are significantly different, though, when doctors were asked how the Internet benefitted–or failed to benefit–them.

13% did not report any problems for themselves and the health service and. . .49% reported 2 or more problems. . . .20% did not report any benefits and . . .21% reported 2 or more benefits.

The authors conclude that overall, doctors aren’t exactly huge fans of their patients’ medical use of the online research, and the doctors believe access causes them more problems than it solves.

These doctors reported patient benefits from Internet use much more often than harms, but there were more problems than benefits for the doctors themselves.

The ‘Smidgen’ Concern

Let me close with what may be a subconscious–and totally understandable–concern on the part of doctors, separate from the other two.

While certain aspects of mHealth require extra time and effort on the part of doctors [more food journals for diabetics, more and more detailed mood charts from those with bipolar, more symptom monitoring from heart patients, and--above all--more graphics of Grandma-Susie-induced headache pain], according to Float Mobile Learning, 40% of doctors believe that using mobile health technologies will reduce patient visits.

Yet patient visits are what doctors get paid for. Thus mHealth can easily look like more work for less reimbursement–a cause anyone would find hard to rally around.

For doctors to embrace mHealth would mean a radical re-structuring of their very sense of their position relative to the patient. That could clearly be a painful shift.

But it seems likely that the future of healthcare lies with mHealth, and those who resist are in peril of being left behind–and sadly bereft of the opportunity to view fascinating colorful Tegretol-nausea graphs.

REFERENCES

Anderson JG, Goodman K. The impact of cyberhealthcare on the physician-patient relationship. Journal of Medical Systems 2003; 27(1):67-84.

Hafner, K. Can the Internet cure the common cold?” The New York Times July 9, 1998.

Harris Y. Exploring the Value of Mobile Health. Clinical  Informatics Insights February 2012.

Malone M, et al. Health and the Internet—changing boundaries in primary care. Family Practice 2004; 21(2): 189-191.

Powel JA, Darvell M, Gray JAM. The doctor, the patient and the world-wide web: how the internet is changing healthcare. Journal of the Royal Society of Medicine 2003; 96(2): 74–76.

Potts HWW, Wyatt JC. Survey of Doctors’ Experience of Patients Using the Internet.  Journal of Medical Internet Research 2004; 4(1):e5.

PricewaterhouseCoopers LLP. Emerging mHealth: paths for growth 2012.

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