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What are your thoughts on mobile Apps where doctors diagnose, give advice or prescribe ie. Healthtap, Doctor on Demand, Ask a Doctor, etc?
Mobile Apps
- Thread starter F0nzie
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Mostly wondering where things stand with e-malpractice. Does a ToS and advice to see a physician in person truly negate responsibility in the eyes of the law?
If everything serious is referred to a physician, is there really a value-add? Can e-triage be effective enough to curb truly unnecessary care?
Telemedicine involves a significant video interaction, whereas a lot of these $$ for medical advice sites require little more than a paragraph and maybe a picture. How do they ensure quality?
Then there's ginger.io, whose pivot is away from predicting depression to providing telemedicine/MH. It's an interesting model when a startup plans to provide therapy directly via their app.
(Most of my thoughts appear to be questions, sorry for the overused rhetorical device.)
If everything serious is referred to a physician, is there really a value-add? Can e-triage be effective enough to curb truly unnecessary care?
Telemedicine involves a significant video interaction, whereas a lot of these $$ for medical advice sites require little more than a paragraph and maybe a picture. How do they ensure quality?
Then there's ginger.io, whose pivot is away from predicting depression to providing telemedicine/MH. It's an interesting model when a startup plans to provide therapy directly via their app.
(Most of my thoughts appear to be questions, sorry for the overused rhetorical device.)
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I suppose I could see the value but I think medicolegal concerns would significantly limit their efficacy - and perhaps rightly so. For something like very specific, easily articulable concerns, I think there could be great benefit. For example, "I just started taking lisinopril and I noticed my legs are really swollen, what do I do?" As a layman, I would probably pay a premium to be able to submit a question and get a response from a credentialed physician - possibly even a prescription for something if the case is extremely straightforward - without the hassle of going into the office. But if you're a physician, I think it's pretty clear that by offering medical advice to specific patients you establish a doctor-patient relationship and become responsible for their care. Depending upon the difficulty of the question or what the person is requesting (e.g., "I have a cough and SOB," "my chest hurts," "I feel like killing myself," etc.), it simply may not be feasible to answer those questions appropriately and do right by the patient. At that point, you are essentially offering a "go to the ER" vs. "don't go to the ER" answering service, and I wonder just how much value you're offering the patient; though, of course, from the physician's perspective it could be a quite lucrative service with relatively minimal work if the proportion of the cases result in "go to the ER."
Even if you do tell a patient to go to the ER, do you become responsible for their follow-up? What if they don't have a regular physician and you're their only point-of-contact for managing this issue? Are you then obligated to provide them with follow-up if you're unable to competently care for them within the confines of telemedicine which are likely to be extremely limited in the context of an app?
I dunno. I think it's an interesting intersection of medicine and technology, and I do think we are likely to see this in the future, but I'm not so sure that we're there yet. There are too many gray areas. I think these "first in the field" endeavors are taking a pretty enormous risk in what they're doing with a potentially huge upside. I think we have yet to see which side the coin will land on.
Even if you do tell a patient to go to the ER, do you become responsible for their follow-up? What if they don't have a regular physician and you're their only point-of-contact for managing this issue? Are you then obligated to provide them with follow-up if you're unable to competently care for them within the confines of telemedicine which are likely to be extremely limited in the context of an app?
I dunno. I think it's an interesting intersection of medicine and technology, and I do think we are likely to see this in the future, but I'm not so sure that we're there yet. There are too many gray areas. I think these "first in the field" endeavors are taking a pretty enormous risk in what they're doing with a potentially huge upside. I think we have yet to see which side the coin will land on.
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Good point. Perhaps determining if giving advice would constitute a doctor-patient relationship? If it does, when does the relationship end? Does it end when the question is answered?
What about providing medical advice when you only have a 1 dimensional view of the patient? ie. no records, no collateral, no formal interview, no physical exam. The differential diagnosis becomes enormous...
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With all the CYA documentation we learned in training I find it hard to believe that so many physicians would open themselves up to this kind liability. I wonder how much liability the App developers will be responsible for...
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Look at how some state laws have been changed so that anybody can order blood tests without written authorization from a doctor. Theranos founder now worth 4.5 Billion.
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What's great about consumer health technology is that the market and scale allows the tech to become much cheaper. I've had Holter monitors where the non-return fee (price of the device) is $3,000. But you can get an EKG device, though less extensive than a Holter recording, now for about $40 and use an app to get a board-certified cardiologist to interpret the results for $12 (AliveCor). The AliveCor app has an algorithm that is FDA approved to recognize a-fib at no cost to the patient. Qardio is coming out with an ambulatory EKG model that has FDA approval soon. And think about the boon that glucometers have been. And prior to people commonly owning their own blood pressure machines, the measurements taken at a doctor's office every couple of years were not nearly as informative as regular readings in various environments. You can now even buy an AED from Costco for $1,000.
I had bradycardia a few weeks ago on a weekend and was able to take my EKG at home on a device I purchased for $40. I was able to send a PDF of the read out to my cardiologist by e-mail, and he was able to interpret it immediately. He tested it later in his office with his own EKG machine and was amazed at the accuracy. It's only one-lead, but very accurate for what it does.
I think that Theranos company mentioned is great. It costs so much to see a doctor without insurance and if you can get a test for something you suspect is affecting you, why not? Getting your cholesterol checked or Vitamin D levels evaluated can be very good health choices for people who can't afford to see a doctor. And even if they could afford to see a doctor, it's not as if most doctors don't acquiesce to the testing patients want anyway.
To me this seems very democratic. This seems to be what Americans have been clamoring for--market-based healthcare.
To argue that the government should step in and protect a certain class of labor as the only legitimate providers of healthcare seems rather antithetical to what Americans claim to have wanted for decades.
Having said that, doctors and other healthcare professionals are necessary, and I think our state-based systems continue to be a mess. While the exchanges are more reasonably priced than what we had before, the system is far too complicated still, too fractured by state, and it leaves way too many out.
I'm in Virginia and had our governor not opened his mouth on gun control the week before this last election we might have tipped the balance for democrats in the state senate and been able to expand medicaid. I read a fascinating article about a man in Kentucky who is clearly benefitting from Medicaid expansion and voted against it:
https://www.washingtonpost.com/nati...43a0ea-8492-11e5-8ba6-cec48b74b2a7_story.html
I had bradycardia a few weeks ago on a weekend and was able to take my EKG at home on a device I purchased for $40. I was able to send a PDF of the read out to my cardiologist by e-mail, and he was able to interpret it immediately. He tested it later in his office with his own EKG machine and was amazed at the accuracy. It's only one-lead, but very accurate for what it does.
I think that Theranos company mentioned is great. It costs so much to see a doctor without insurance and if you can get a test for something you suspect is affecting you, why not? Getting your cholesterol checked or Vitamin D levels evaluated can be very good health choices for people who can't afford to see a doctor. And even if they could afford to see a doctor, it's not as if most doctors don't acquiesce to the testing patients want anyway.
To me this seems very democratic. This seems to be what Americans have been clamoring for--market-based healthcare.
To argue that the government should step in and protect a certain class of labor as the only legitimate providers of healthcare seems rather antithetical to what Americans claim to have wanted for decades.
Having said that, doctors and other healthcare professionals are necessary, and I think our state-based systems continue to be a mess. While the exchanges are more reasonably priced than what we had before, the system is far too complicated still, too fractured by state, and it leaves way too many out.
I'm in Virginia and had our governor not opened his mouth on gun control the week before this last election we might have tipped the balance for democrats in the state senate and been able to expand medicaid. I read a fascinating article about a man in Kentucky who is clearly benefitting from Medicaid expansion and voted against it:
https://www.washingtonpost.com/nati...43a0ea-8492-11e5-8ba6-cec48b74b2a7_story.html
Blackburn was making small payments on an MRI he’d gotten at Pikeville Medical Center, the only hospital in a 150-mile radius, when he heard about Big Sandy’s Shelby Valley Clinic. There he met Fleming, who helped him sign up for one of the managed-care Medicaid plans available in Kentucky.
On Election Day, Blackburn voted for Bevin [the governor elect who has promised to dismantle Medicaid expansion] because he is tired of career politicians and thought a businessman would be more apt to create the jobs that Pike County so needs. Yet when it comes to the state’s expansion of health insurance, “it doesn’t look to me as if he understands,” Blackburn said. “Without this little bit of help these people are giving me, I could probably die. . . . It’s not right to not understand something but want to stamp it out.”
This is a part of my fellow Americans I really, really don't understand. This guy voted for a man on the promise he would take away his health insurance.On Election Day, Blackburn voted for Bevin [the governor elect who has promised to dismantle Medicaid expansion] because he is tired of career politicians and thought a businessman would be more apt to create the jobs that Pike County so needs. Yet when it comes to the state’s expansion of health insurance, “it doesn’t look to me as if he understands,” Blackburn said. “Without this little bit of help these people are giving me, I could probably die. . . . It’s not right to not understand something but want to stamp it out.”
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Because it's not as simple as just getting one test and making a decision based on that. It certainly doesn't take a doctor's training to order a single test and make a decision based on that, but as doctors, we know that it may be something more complicated. That's why we ask questions about history, do an exam, and order more than one test.
I don't think most people really understand this, and that's partly why they're ok with lesser trained professions having the same practice rights. Most people don't see the thought processes going on in doctoring. But I can assure you that practicing medicine properly is a more complicated endeavor and the apps described above that try to simplifiy it all will likely lead to bad outcomes.
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It does look like society's attempt to dumb down the practice of medicine to tech support. Body hurts? Reset it and wait for all 4 lights to turn on. Caution: body may not turn back on.
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Isn't that what a coma is technically?
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I think this is a case where the technology definitely is ahead of the times. Liability issues with apps like this are huge in my opinion. I think telemedicine is just now catching up to liability/legal issues where things are more clear and it's really taking off. The apps are not quite there yet.
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It is clear that the hype (or excitement about the potential) of mobile mental health technologies has exceeded the clinical evidence base. Look on pubmed for what we have clinical evidence that these apps can do in psychiatry. There are some feasibility studies and no true efficacy studies. When folks set out to seek efficacy, results have been very unimpressive (http://archpsyc.jamanetwork.com/article.aspx?articleid=1847578) and then implementing such apps in the real world has been even more unimpressive (http://www.jmir.org/2015/8/e201/). Right now we are not 'there' and rather there is a series of critical but basic questions that still remain unknown. The first of these is are these apps safe. How can an app cause risk or danger? Take the case of this one that aimed to reduce drinking in college students but led to higher rates of drinking (http://www.ncbi.nlm.nih.gov/pubmed/24985342). Next are the liability questions are raised above. Then efficacy. Then which patients are actually using these apps....what if it is only the worried well. The list goes on.
Yet for all that negative talk - the potential is there...and we will realize it one day. That day may be sooner than we imagine - but will not be next week or next year. It is a good research area for residents (and medical students) to jump into. Plenty of review papers and basic studies needing to be done! Happy to discuss more
Yet for all that negative talk - the potential is there...and we will realize it one day. That day may be sooner than we imagine - but will not be next week or next year. It is a good research area for residents (and medical students) to jump into. Plenty of review papers and basic studies needing to be done! Happy to discuss more
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Another FYI I learned about this week at AAAP: http://sudtech.org/
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Differential diagnosis apps can be useful to doctors. Using interactive clinical algorithms, apps can provide a step-by-step approach to recognizing and differentially diagnosing diseases.
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Any recent thoughts on technology and Psychiatry? I'm seeing more and more young doctors go into tele-medicine. Curious what this community thinks about their benefits and / or what it still lacks. What would your wish list for technology be?
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Out of curiosity, I asked some of my patients if they would be interested in communicating with me online (Telemedicine). Many basically said, "why should I spend a lot of money to be told to go to the ER." They feel safer coming in were they can be seen.
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Telepsych exists in its current state primarily of necessity although that trend could change. My previous CMHC discontinued the telepsych program at our location because patients flat out refused (both new and existing patients). These patients were not paying for their treatment yet many preferred no treatment to telepsych. The setup matters ie. screen resolution, bandwidth... But I think times are changing and there will be less of a gap between the user and the screen. The young generation would probably see telepsych as an extension of Snapchat and would get a kick out of my augmented reality glasses and puppy ears. Next is virtual reality-- just when you thought office overhead couldn't get any lower.
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