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My Wish List for Apple’s HealthKit Initiative

June 23, 2014

Apple has been making headlines again, which is not unusual for a company that sets trends and moves markets. A week or so ago they announced that iOS 8 would have a built-in app to collect all of your health info in one place. Then there was the announcement of the partnership with Mayo Clinic and Epic Systems. This generated even more headlines.  I saw all kinds of opinion pieces published, ranging from predictions that this will be the ‘game changer’ that mHealth has been waiting for, to those who said, “Not so fast. What is really novel here?”  I let the dust settle, processed all of this, and came up with the following reflections.


It’s impossible to give an educated opinion because all we’ve seen so far are some hints at what the software will do. We have no idea what the hardware play will be and we don’t yet know all of the planned software capabilities. However, there are some things I believe we can count on.

Apple has an amazing track record of creating superbly designed, intuitive software and beautiful, flawlessly integrated hardware.  By contrast, virtually all software created for health care users (providers, patients and administrators) is poorly designed.  If Apple offers some breathtaking software and very sexy hardware to help us stay healthier, it could make a difference, or at least point the way for others as the iPod and iPhone did.

Also, hats off to Epic and Mayo Clinic for showing us the way on the integration of patient-generated data into the electronic health record.  If the platform gets traction with Mayo clinicians and/or if they can show patient-generated data being used to improve health outcomes or lower cost, this could be a very big deal.

I can’t help but be optimistic.  But I also can’t resist playing armchair quarterback and offering some advice as the effort goes from screen shots to reality.  With so much opportunity to be transformative, I hope they take up that mantle seriously and don’t repeat the mistakes of recent connected health history.  Here is my wish list for Apple as they launch HealthKit.

  1.  Please don’t think that a health data repository on a mobile device will be transformative.  Google discontinued its health data repository and Microsoft’s has gotten very little use.  We (society, health care experts, providers) have not given consumers/patients enough of a reason to make the effort to store all of their health data on one platform.  People don’t feel compelled to take ownership of their health data.  The only compelling use case is the traveler who gets ill and that just isn’t enough.  Yes, HealthKit will make the collection of health data mobile and most likely passively captured. But overcoming these consumer barriers will not be enough to assure widespread adoption, I fear.
  1. Please don’t make it just about seeing your doctor’s notes/lab data, etc., on your mobile device.  This would be under-imagining the potential of this type of platform.  I’m assuming that with the wave of wearables and Apple’s interest in health tracking, we will see heavy integration of patient-generated data. But, assuming is dangerous, so this is my explicit plea to Apple to do lots with patient-generated data, both collected via a device and self-reported.
  2. Please do employ analytics on all of the data streams to feed insights to users in order to help us to improve our health.  This seems obvious, but I worry. At the Center for Connected Health, we have accumulated lots of evidence that personalized engagement messaging is what will make something like HealthKit sticky over the long run.  I don’t see evidence that Apple has done this.  

    Apple does OK at best, while companies like Google, Amazon, Netflix and Facebook live and die on their analytics ability.  Other than iTunes, can you think of a software application that Apple created that is superior?  Apple excels at many things, but any time they’ve been challenged to use analytics to target messaging and personalization, it has not gone so well. Just look at the example of Ping, Apple’s attempt at a social network, or how iTunes Radio stacks up to Pandora. We know there is no comparison to great machine learning as it pertains to keeping individuals engaged. I don’t see this as a core competency at Apple.

For me, it boils down to this:  Will easy-to-use, intuitive, engaging software and beautifully designed hardware be enough to bring people into an environment like HealthKit and keep them there? Or will it take a killer app with analytics to drive personalization to keep people engaged (a la Netflix recommendations, Pandora’s predicting songs for you or Google knowing exactly what your searching for after only three keystrokes).

If you are in the former camp, you predict Apple will be remembered for changing the game in connected health.  If you are in the latter camp, you may be seeing HealthKit go the way of Ping or Google’s health data repository.

What’s on your wish list for HealthKit?

Join Us to Jam About Connected Health

June 10, 2014

As part of our mission at the Center for Connected Health, ‘to create and validate connected health solutions that empower patients and providers to transform care,’ we also engage in a number of activities to help move healthcare forward.  Our management team is often found at the podium at industry conferences, roundtable discussions, government hearings, grand rounds and other venues sharing our experience and vision; we participate in webinars, tweetchats and media interviews to help inform and motivate people to embrace health technologies.  We also host our annual Connected Health Symposium, which gathers over 1,200 industry, clinical, patient and government leaders from around the world to discuss, debate and ultimately integrate healthcare into the day-to-day lives of patients.

Next week, the Center is pleased to be participating in a first-of-its-kind online forum for the health technology ecosystem, the Innovation HealthJam, taking place June 17-19.  The Innovation HealthJam is a virtual event that brings together a diverse and knowledgeable group of people from the healthcare and technology fields to brainstorm ideas, improvements and innovation in healthcare.  We are hosting a track within the HealthJam, focusing on remote patient monitoring.

The Center is very proud to have gathered a highly-respected and experienced panel of experts to discuss the benefits, opportunities and applications of remote patient monitoring.  Remote patient monitoring can deliver timely information to healthcare providers to increase quality of care, and decrease healthcare delivery costs.  Our research and clinical programs in heart failure, diabetes and hypertension have proven this time and again.

I’m privileged to be moderating the discussion, with our panel, including Larry Brooks from Boehringer-Ingelheim, Chris Hendriksen from VRI, Vicki Smith from Qualcomm Life, Jasper zu Putlitz from ansacloud and Khinlei Myint-U from our team here at the Center.  These speakers bring years of experience and unique perspective to address issues ranging from the applications of RPM for pharmaceutical manufacturers, scalability, technical connectivity and the implementation of remote patient monitoring programs.

HealthJam attendees are encouraged to join in this virtual discussion, share ideas, promote innovation and help us answer some important questions, including: Will patients feel empowered to better self-manage their health or will they perceive home monitoring as a ‘safety net’ instead of a preventative measure?  How will healthcare providers be able to use all the transmitted data to diagnose quickly without being overloaded?

Remote patient monitoring can improve chronic disease management and provide important support for those newly discharged from the hospital.  It can also allow clinicians to provide just-in-time care for some of our sickest patients, and help keep people healthy at home.  Join us next week to share your ideas, successes and challenges. Together, we hope to find more answers, create more opportunities and help more providers and patients improve clinical outcomes and quality of life.

For more information or to register, please visit the Innovation HealthJam website.

Hope to Jam with you next week.

For Telehealth Patient Safety Insists Upon An Evolution In Policy

June 4, 2014

This post first appeared in Health Affairs:

Joseph Kvedar, For Telehealth Patient Safety Insists Upon An Evolution In Policy, Health Affairs Blog, May 29th 2014,
Copyright ©2010 Health Affairs by Project HOPE – The People-to-People Health Foundation, Inc.

Editor’s note: For more on this topic, see the February issue of Health Affairs, which features a series of articles on connected health.

The nation’s ongoing battle to strike a delicate balance between increasing access to quality health care for all Americans and reducing overall health care spending just scored one of its most substantial victories.  In late April, after several months of thoughtful and robust collaboration, the Federation of State Medical Boards (FSMB) ratified a new model national policy – the Appropriate Use of Telemedicine in the Practice of Medicine – at its annual meeting in Denver.  This marks the first time the medical community has unilaterally acknowledged the impact technology has had on the practice of medicine, and the ability telemedicine — or connected health — has to facilitate and improve the delivery of health care.

Let us first put this in perspective.  We all know health care is at a critical juncture.  The implementation of the Affordable Care Act means millions of newly eligible Americans will seek access to an already over-burdened health care system.  The nation faces a serious shortage of primary care providers, specialty care is becoming more diversified, and access to care in rural areas is an ongoing challenge.  All of these issues are on the rise.

Technology-enabled Care

Enter technology-enabled care.  Real-time video encounters between patients and providers reverse the burden on patients to seek care in a hospital or doctor’s office by bringing health care directly to them, in their home.  At the same time, remote monitoring, sensors, mobile health and other technologies are helping to reduce hospital readmissions, and improving adherence to care plans and clinical outcomes, as well as patient satisfaction.  Connected health tools also support preventative care efforts for chronic care patients and can empower individuals to make positive lifestyle changes to improve their overall health and wellness.

Momentum for telehealth is accelerating at an undeniable rate.  As of March, twenty states and the District of Columbia have passed mandates for coverage of commercially provided telehealth services; 46 states offer some type of Medicaid reimbursement for services provided via telehealth.  A study by Deloitte predicts that this year alone, there will be 100 million eVisits globally, potentially saving over $5 billion when compared to the cost of face-to-face doctor visits.  This represents a growth of 400 percent in video-based virtual visits from 2012 levels, and the greatest usage is predicted to occur in North America, where there could be up to 75 million visits in 2014.  This would represent 25 percent of the addressable market.

Yet, there exists an inconsistent and often archaic patchwork of state laws that have inhibited the deployment of telehealth in both the private and public sectors.  As a result, both providers and patients are in a state of limbo, prompting such questions as: Can I, as a provider, deliver care while still being compliant in all 50 states?  Can I, as a patient, trust the care I receive via telehealth is safe and secure?  These uncertainties have created an unnecessary barrier to realizing the true promise of telehealth.

Model Policy For Telemedicine Technologies

The Federation of State Medical Boards recently took action by forming the State Medical Boards Appropriate Regulation of Telemedicine (SMART) Workgroup.  Through a thoughtful nearly year-long process which included a broad cross-section of stakeholders, the SMART Workgroup developed the “Model Policy for the Appropriate Use of Telemedicine Technologies in the Practice of Medicine.”  This insightful document provides states with clear definitions and principles they can look to for guidance when developing new policies that govern telehealth.

Among these principles are these key concepts:

  • Evaluation and Treatment of Patient.  Treatment delivered in an online setting should be held to the same standard of appropriate practice as those in traditional settings.
  • Establishing a Treatment Relationship Online.  A physician-patient relationship can be established using telemedicine, so long as the standard of care is met.
  • Online Prescribing Safeguards.  Prescribing in a telehealth encounter should be at the discretion of the physician.
  • Ensuring Privacy, Security, Documentation, and Continuity.  Telehealth encounters should be HIPAA compliant, include informed consent, the generation of a medical record, and support continuity of care.

I applaud the Federation, the SMART Workgroup, and their guidance.  Telehealth is happening; it’s becoming an accepted practice across the United States.  This Model Policy allows for regulatory certainty while encouraging future innovation by creating clear definitions and guidelines on how and when telehealth can be most effectively incorporated into quality patient care.

States must now take action and adopt these policies.  Failure to do so is not just inaction, it is irresponsible.  The use of connected health tools will increase, and with thoughtful, modernized policy, providers and patients can be assured that technology-enabled care will be safe, secure and uphold a standard of quality care consistent with care delivered in person.  The Federation has done its work as national leaders, and now it is time for state leaders to do their part to advance health care delivery in every state throughout the country.

Making Health Addictive: Use The Sentinel Effect

May 29, 2014

Since I gave a keynote at the 2013 Connected Health Symposium called “Making Health Addictive,” I’ve been posting on this topic in order to explain some of the concepts in more detail and to get your feedback.  Previous posts include a framing post, and further detail on what I laid out as three strategies to achieve addiction to healthy behaviors: “Make it About Life” and “Make it Personal” and “Reinforce Social Connections.”

In early February, I wrote about tactic one, Employ Subliminal Messaging, and last month on tactic two, Use Unpredictable Rewards.  This post is on the third of three tactics, Use the Sentinel Effect.  I realize there is a lot of required reading if you are just checking in to this series.  If you want to absorb the full concept, it is worth reading all of them. If you’d like the Readers Digest version, you can get away with the framing post as background.

Making health addictive is really about harnessing the power of our fascination with mobile devices, particularly smartphones.  We check these devices up to 150 times per day.  What if we put a personalized, relevant, motivational and unobtrusive message in front of you some of those times?  Could we induce permanent behavior change?  I am searching for examples of these customized mobile, personalized messages and any resulting behavior change, so if you know of any, please let me know.

The Sentinel Effect is: The tendency for human performance to improve when participants are aware that their behavior is being evaluated; in contrast to the Hawthorne effect, which refers to behavior change as a result of being observed but not evaluated.  Both are useful tools in the context of connected health.  I’ve emphasized the sentinel effect because in our experience, patients significantly increase their adherence to a variety of healthy behaviors when they know that their physician (or her agent) is watching.

About seven years ago, we began working on platforms to allow patients to upload biometric data.  These data act as both a feedback loop for patients themselves to use as a yardstick for health improvement, and also as a mechanism for patients to give their providers access to a richer tapestry of data on which to base care decisions.  This combination of feedback loop plus provider oversight worked well for us.  In the case of congestive heart failure monitoring, we saw a 50% drop in readmissions;  patients with hypertension achieved a significant drop in both systolic and diastolic pressure; and people with diabetes experienced a meaningful drop in HbA1c.

Because the hardest challenge for us to solve was the round-trip data connectivity — from the sensors in the home to the cloud to the EMR and patient portal — we assumed that this was the magic key to the success of these programs.  However, when we asked the patients and the nurses caring for them what made these programs work, we heard a unifying theme from both parties.  We learned, what mattered most, is that patients worked hard to improve their health because they knew their nurse was watching and didn’t want to disappoint her.  Some patients went so far as to say they’d only participate in uploading their self-monitored data if they knew that their doctor and/or nurse were looking at it.

Here are three video clips that illustrate this:

First from one of our patients, George Ruboy, who talks about his personal experience with Connected Cardiac Care, our heart failure tele-monitoring program:

The mirrored reflections of one of our nurses, Karen Federico, are presented in this video clip:

Lastly, from a pharmacist who has used our Blood Pressure Connect program to manage many patients with hypertension:

This most basic of human psychologies is related to strategy number three, Reinforce Social Interactions.  Some social interactions are motivating because we want to brag to our friends, because we want our friends to be a support group or because individuals in our social network are holding us accountable.

The Sentinel Effect is a really powerful tool, but is  based on a fairly primitive psychology. Essentially, we don’t want our parents to catch us falling off the wagon.

It’s great that we learned about the synergistic relationship between objective, patient-generated data and the Sentinel Effect.  If the same programs were based on self-reported data from patients keeping a written diary, for example, we’d have much weaker outcomes.  Patients would report those data that make them look healthy and ignore those that do not.

Now, we’re contemplating whether we actually need a nurse or doctor as the sentinel.  For these algorithmic conditions, like uncontemplated hypertension, could we employ software to do the monitoring, rather than having a doctor or nurse monitor the patient data.  But would patients be as responsive and diligent managing their own health?  Early results suggest this is possible.  It is the next generation of connected health solutions.

Let me know your thoughts.

How much can we demand of consumer connected health?

May 2, 2014

A few years back, when I first became fascinated by self-tracking, I committed to use and understand all of the trackers on the market at the time.  It would be hard to make that kind of commitment today as the field has widened dramatically. But in 2009, it was much more confined. I had a BodyMedia armband, a Withings scale and a FitLinxx ActiPed pedometer.  One thing I learned early on was that their readings don’t always hang together well.

For instance, we know that much of daily weight fluctuation is about salt intake and fluid retention, and the body composition function on the Withings scale has trouble with that.  Here are two real readings from me on recent successive days:  weight 186.6, fat mass 25.59, then 184.6 and 24.03.  Logic would dictate that if I lost 2 lbs in one day it would have to be water weight and my body fat composition should go up not down.

I had the same early consternation with the BodyMedia armband and the ActiPed.  FitLinxx is on the record as saying their technology measures steps most accurately. BodyMedia uses a proprietary algorithm that includes a number of inputs.  My personal data recorded on these two devices were routinely different.  When Fitbit came out, I say that device gave a different number still.

It gets even more peculiar when you use MyFitnessPal to count calories in and try to map the calories/calories out (based on an activity monitor) with the weight readings from Withings.

You get the picture.  Quantified selfers, like me, are asking too much of these simple technologies.

What I learned over time is that these tracking devices are directionally correct.  They are most helpful when the data from each sensor is viewed longitudinally, in its own context.  For a time I wore both a Jawbone UP and a Fitbit and I found that though the step counts registered were quite different on each activity tracker, the percentage variability of each from day to day was pretty consistent. In my experience, they are internally consistent.

Acitivity trackers_Wellocracy_cHealth blog kvedar

This is all background to comment on an article by Nick Bilton that was featured in this past Monday’s New York Times, entitled:  For Fitness Bands, Slick Marketing but Suspect Results.  In this article, Bilton makes the case that activity trackers are really inaccurate.  He mentions personal experiences where he and a friend were both wearing the same monitor, at the same time doing the same thing, and got wildly different results. He also reported another incident when he was using his smartphone’s GPS tracker to measure his activity and, though he was sedentary, it showed him to have been active.

First off, I have not reproduced experiences like either of these.  However, it’s worth noting that the technologies are nowhere near perfect.  The standard technology to measure activity is an accelerometer and it is only as good as the software algorithm guiding it.  Almost all activity trackers know when you are driving a car or riding a bike and don’t count that.  However, bouncing your leg up and down while at rest or swinging your arm back and forth can yield false positive results.

Sleep trackers are even worse.  Since they track sleep indirectly by measuring activity, they are all over the map.

Expecting these consumer devices to have scientific accuracy is unrealistic.  Expecting them to help you keep your activity level top of mind and measured in context from day to day is realistic and in most cases helpful.

Our experience using activity monitoring in programs at the Center for Connected Health has demonstrated this.  The objective feedback is helpful in setting a tone for the individual and as a data stream to guide motivational tools such as automated coaching.

Acitivity trackers2_Wellocracy_cHealth blog kvedar

For example, one of our physicians at Mass General Hospital gave nine of her patients with diabetes a Fitbit Zip  and met with them, as a group, weekly.  After six weeks, nearly 80% of these 60 plus year old patients increased their amount of weekly exercise, in particular walking, and 22% lost a significant amount of weight, with one patient losing over 10 lbs.  More than half of these patients are still using their Fitbits, eight months after the program was completed, and all reported that they felt more confident in their ability to care for themselves, and everyone was moving more.

We never expected consumer devices to be as accurate as laboratory calculations of activity level or calories burned.

One of the reasons we launched Wellocracy was to help consumers understand nuances like this.  So far it’s been a great success.

Does it matter if every step is counted, every calorie recorded, or is it more important that these personal health technologies are making us more aware, more motivated and more likely to make healthier lifestyle choices?

Making Health Addictive: Use Unpredictable Rewards

April 24, 2014

Since my presentation at the 2013 Connected Health Symposium, “Making Health Addictive,” I’ve been posting on this topic in order to explain some of the concepts in more detail and to get your collective feedback (always incredibly helpful).  Previous posts include a framing post, and further detail on what I proposed as three strategies to achieve addiction to healthy behaviors, “Make it About Life,” “Make it Personal” and “Reinforce Social Connections.”

In early February, I wrote about tactic one, Employ Subliminal Messaging.  Here is my post on the second of three tactics, Use Unpredictable Rewards.  The third and final tactic, Use the Sentinel Effect, will follow in my next post.

Use Unpredictable Rewards_Kvedar

Making health addictive is really about harnessing the power of our fascination with mobile devices, particularly smartphones.  We check these devices up to 150 times per day.  What if we put a personalized, relevant, motivational and unobtrusive message in front of you some of those times?  Could we induce permanent behavior change?  I am searching for examples of these customized mobile, personalized messages and any resulting behavior change, so if you know of any, please let me know.

The concept of unpredictable rewards brings us closer still to the vision of what Making Health Addictive might look like on your mobile device.  This tactic is what the mobile industry has capitalized on to get you to check your device 150 times a day.  Now, we just need to corral the power mobile devices yield, to call your attention to relevant, personalized health messages, and change our behavior for the better.

This tool for behavior change is not new.  In 1948, when B.F. Skinner did his famous operant conditioning experiments, he measured rat salivation in response to presenting a food pellet to the rat.  In the background, he also rang a bell when the food pellet was presented.  After a while, he observed that the rat would salivate when the bell rang, whether the food pellet dropped or not.  The response was even stronger, however, when the food pellet was presented randomly.  This observation was the beginning of the science of variable rewards.

Advertisers use this concept often, as they know how effective it is.  One recent noteworthy example comes from the company Uber.  Undoubtedly you have heard of Uber. They’ve turned the process of flagging a taxi upside down and in the process created a much more pleasant customer experience.  Recently, they have done something else to increase the likelihood that a user will open their app.  Every now and then, when you open the Uber app, you will see an offer for something completely unrelated to getting a ride. It might be a discount on flowers or show tickets. They do this randomly and even though it’s not part of their core business, they have demonstrated that people open the app more often knowing that this unpredictable reward might be there.

uber_ice cream

Actually, when you think about it, this is the fundamental psychology that underlies why we check our mobile devices so many times.  There is so much new content (emails, texts, news, etc.) and it changes so rapidly that we become like Skinner’s rats.  We have to check the devices constantly.

This tactic marries quite effectively with subliminal messaging.  If we could design an app so that every time you check your phone, there is a relevant health message in the path (it can’t appear every time and it can’t be obtrusive; it might not need to even be noticeable), we may be able to change health behavior in a way that would seem almost effortless.

Recall our study on the use of text messages to improve sunscreen adherence.  In this study, we sent folks in the intervention arm a daily text message with the weather report and a reminder to put on sunscreen.  The group did remarkably better than a group of subjects who did not receive the messages. When we asked the subjects what they found compelling about the text messages, many said they liked getting the weather report.  They barely paid attention to the messaging on sunscreen use.  But it changed their behavior.

Sunscreen adherence study_message

There is something to this.  Last fall, Facebook released an app that would take over your home screen so that any time you open your phone, you see your Facebook updates before anything else.  It hasn’t done too well, perhaps because it feels too invasive.  But what if your health plan (or provider in an accountable care world) offered you a reduced premium for services if you agreed to get a health message mixed in (randomly but on average every 10 emails or texts) with your other messages.

Would people consider this too invasive? Would the reduction in premium costs be enough to motivate use?

What are some other applications for unpredictable rewards to improve health?

Direct-to-Consumer Telemedicine: Has its time come?

April 10, 2014

It was 1999, and I was speaking at a prestigious academic center’s ‘Innovations in Dermatology’ symposium.  I presented work we had done on a web application that would allow a non-dermatologist (primary care doctor or other front-line provider) to upload images of a patient’s skin as well as some history.  Subsequently, a dermatologist could review both the history and the images and enter a diagnosis and recommendations on the same website.  My talk was greeted with intense scorn by one audience member (“You are cheapening our specialty,” he told me) and general lack of enthusiasm by most of the others.

Fast-forward to 2014.  Dermatologists share digital images via email and a number of social networks thousands of times a day.  If the specialty is cheapened, I can safely say it is not due to this activity.  So far, we’ve not created any ‘cutaneous radiologists’ which was another fear of nay sayers at the time.  In fact, the American Academy of Dermatology has an officially sponsored software application that members can use to provide volunteer teledermatology services to underserved clinics, and is planning on promoting this concept in the coming year. What a difference 15 years makes!

I use this story to set context for a thoughtful discussion on one of the most controversial telemedicine questions of our current time.  Is it safe and effective care for providers to evaluate and prescribe for patients that they’ve never met face-to-face?

Join me in thinking through this question.

1.  Most health care requires authentic relationships.

You don’t have to go very far to find graphic stories about folks who form relationships online.  These relationships become quite ‘close,’ then the parties meet face-to-face and find that one or both was being highly deceptive with their online persona.  It seems safe to conclude that the possibility of fraud in online relationships is much higher than in person.  Most clinicians feel that forming a relationship with their patients is a core part of providing quality health care.  Until this authentication challenge is solved, it’s hard to imagine many health care interactions with new patients being conducted in an online environment.  Some of you may be thinking that ubiquitous, embedded videoconferencing solves this and certainly adds a great deal of value beyond text-based interactions.  But I don’t know if we can say applications like Skype and FaceTime are the complete answer.

2.  How do we define quality care in this new environment?

When you go to a hotel, you expect clean sheets and towels, a warm shower, a bed you can sleep in, and comfortable room temperature.  What are the same minimum quality requirements for an initial doctor’s visit?  As doctors, we’re taught that this includes a complete medical history and physical exam relevant to our specialty.  As a dermatologist, I am not expected to do a complete neurological exam (you should be thankful for that) but unless you decline, I am expected to do a complete skin exam, even if you come in for a 4 X 4 cm patch of poison ivy on your arm.  This is something that I really cannot do online, even with current state-of-the-art technologies.

The idea of allowing patients to upload images of body moles or facial acne for evaluation by providers they have not ever met gives many of my colleagues great consternation. (Even more controversial are image analysis scientists who are creating applications that can analyze these images without human intervention.  More on that phenomenon at a later date.)  My colleagues fret that a patient will send them an image of a mole that is benign, but ignore a mole that is an incipient melanoma.  To me, this seems less onerous than the authentication issue.  Patients are capable of managing their own risks when these risks are spelled out.  For example, it seems perfectly reasonable to alert an individual that she may be missing an important lesion if she chooses to submit an image over the Internet, rather than come in for a complete exam.  A closely related fear or objection is one of physician liability.  In this context, the doctor is not only afraid they will provide substandard care by not doing a complete physical exam, but that they may be held liable for that omission.  Once again, spelling out that a patient is taking accountability for those aspects of his care not addressed in an online interaction seems reasonable to me.  I think the liability concerns are overstated.

3.  Is the technology up to the task at hand?

There is not a general yes/no answer to this question.  It is medical problem specific.  The answers are in the realm of clinical research.  Taking you back again to the late ‘90s, we (and many others) did painstaking clinical studies to empirically test whether a set of digital images is of sufficient quality to be a diagnostic tool in lieu of an in person exam.  There now exists a body of literature that demonstrates this equivalency, with the possible exception of some pigmented lesions.  We also carefully examined the feasibility that patients could take their own, clinically accurate, facial images of acne. Are there other examples?  Can a psychiatrist do an initial evaluation of a patient via interactive video?  I am not up on this literature, but my guess is that it has been studied and the answer is yes.  There are probably a few other examples as well.

Where does this leave us in my logical analysis?  To provide a quality care experience online without having met the patient in person, I content that the following criteria would need to be met:

1.  Identify a medical problem that has a diagnostic data set, easily and reliably acquired by a consumer/patient.

2.  Assure that the patient is capable of understanding that the online interaction is problem specific and may carry risks, particularly for omission of care involving other health problems.

3.  Assure that the treatment decisions for the specific condition at hand are algorithmic and do not require an authentic relationship (i.e., the problem is transactional or of low emotional value to both provider and patient).

This is exactly what some folks have done with two fledgling companies, Direct Dermatology and DermatologistOnCall.

Direct Dermatology



They accept images of facial acne and if they are comfortable making a diagnosis, will prescribe a limited array of therapeutics for these patients.  Both are gaining some traction, indicating that there is consumer demand.  Interestingly, since acne images involve the face, it makes it much less likely that an individual can assume a fraudulent online personality.  And even if they decided to have their friend send in facial images what would be the point — to clandestinely procure a prescription for a topical antibiotic?  I’d say there is not much risk on the authentication side in this model.

Another interesting comparison is the rise of retail clinics. These were initially scorned by primary care providers, but consumers are drawn to the convenience.  The repertoire of problems is limited, as are the therapeutic options. Patients are made aware of these limitations and the associated risks.

Perhaps Direct Dermatology and DermatologistOnCall are the vanguard of a new set of medical services that are like retail clinics but delivered in an online environment.  I’ll watch their evolution with great interest.  And I think the risk of cheapening our specialty is low.


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