Once in a while, each of us takes on the role of a personal doctor. When we experience unknown symptoms, very often our first step towards diagnosing them is seeking information online. Actually we are constantly surrounded by mobile technology, so it has become a habit for us to support it. This process is called intelligence augmentation, and in a very simplistic way it is about the technology that we have at our fingertips which allows us to broaden or deepen the problem at hand. We live in an era of knowledge deficit, further supported by continuous, though often apparent, lack of time. So when we care about something we want to have it here and now (I also associate this with the notion of “instant gratification”), especially in a situation related to explanation of reasons of our current, not necessarily good health condition.
The unplanned space between medical ignorance of patients and physicians is trying to fill technology through the mHealth trend (Mobile Health), which rapid development we could notice in recent years (see graph below). Deloitte estimates the current value of the Digital Health market at $ 23 billion, but it is expected to grow to $ 43 billion next year. Mobile applications in the mHealth category (those that rely more or less on a remote patient’s contact with a physician) are today the smallest sub-sector of Digital Health, but at the same time the fastest growing and most promising. According to Deloitte, it is expected to grow by 49% in 2014-2018, and Europe in 2018 will be the largest recipient of this type of remote medical service.
At this point, it is worth to stressed out how the development of AI (Artificial Intelligence) may in the near future affect the medical industry and the time and speed of diagnosing patients. Even today advanced algorithms are able to identify certain medical conditions, such as the first signs of skin cancer, with the accuracy of the doctors, as recent research by Stanford University researchers has shown. Similar accomplishments can be attributed to the SI staff at Google Brain, whose algorithms have previously been trained on thousands of retinal scans to recognize the early symptoms of retinopathy.
Self-learning algorithms supply (and will do it more often) also the latest applications in the field of mHealth. The ADA, a British-German project, has assimilated thousands of medical cases from the past few years as well as hundreds of scientific sources, from major books, research to recent publications. The creators of this solution want the user to have an instant access to a virtual doctor who will be supported by machine intelligence.
Designers of the recently popular Medici and Amino applications are not going to replace the physician with machine learning. Through the aforementioned applications, patients (via SMS or video chat) can contact specialists by paying for their time and advice. In my opinion, this type of application will be telling people about the increasing strength of the mHealth trend, if the model of their action is successful. The first, Medici, with its premiere at this year’s SXSW, is currently available in the USA, and will be launched in five more countries by the end of the year. Its main idea is to offer access to doctors of all specialties, including vet, within one platform. In the US, this application also allows to remotely send an e-prescription to the pharmacy closest to patient. In turn, the creators of Amino, set themselves the goal of matching the best professionals to patients’ needs, especially when they report a rare case of the disease in which treatment does not specialize too many doctors. The application has received $ 25 million for development which shows a great deal of investor interest in this type of solution.
I decided to investigate the subject, and that is why I consulted at the source, asking a fellow doctor, prof. Artur Pupka, a specialist in vascular surgery, general angiology, transplantation and clinical sports medicine what he thinks about the development of mHealth applications, their usefulness and barriers.
What do you think about new ways that remotely connect patients with doctors for advice?
AP: It is worthwhile to begin with the fact that the creation of these solutions is really the consequence of the passage of time. We are constantly surrounded by technology, the network, the virtual world, from which so many people today are using and it is difficult for this technology not to enter the medical field as well. But these changes are very different for young doctors, especially young patients. I am raised by the “Old Masters” of the scalpel and headphones, and I always tell my students that the patient – in order for them to be able to go out, diagnose, cure – must be examined, it means that physical examination and family medical interviews are required. At this stage, attention is paid to many minor details and can be inferred from direct contact with the sick.
Although what I said is also somewhat in contradiction to what I sometimes do, though only seemingly. My patients, those I know, I examine in my surgery, constantly treat or do vascular surgery, especially the least invasive, have contact with me, mostly by texting, e-mails and telephone.
During such consultations, I also give them advice remotely , but the difference is that I know these patients. I know what is wrong with them and what is the history of their illness and treatment. Nevertheless, very often such virtual consultations end in direct contact in my surgery. Every month I also receive dozens of e-mails from patients who live far from the place where I work. They ask about various illnesses but most often they contact me virtually for the initial consultation of a very rare medical condition (upper thoracic compression). I am practically the only doctor in Poland who is treating and operating this syndrome. These patients find out about it from the Internet and before they come to me, they often send me online their medical check-ups for inspection. I send them my opinion, but at the same time I say that I still have to see them, examine, do ultrasound and then we can talk about further steps. I made such a broad introduction to stress the fact that I think that applications you ask me about are ok, but they also have some important limitations. They certainly should not be seen as medical advice and trust them at 100%. Such applications may serve to guide the patient, give some general advice, based on hard medical dogma, related to the treatment of specific diseases. But to start the patient heal seriously, he must come to me for a medical visit, so I have to talk to the patient and examine him. The remote medical contact with the physician through the application is acceptable for me, but we have to remember about the existing limitations.
Another issue is how to price consultations within such an application. In the case of patients that I examine and treat, I do not charge them extra fees for calling or writing e-mails and they receive such additional advice from me. I am aware of the fact that sometimes it happens that the cost of such additional consultation is added by some doctors to the cost of the whole treatment. Another situation is when completely new patients send me remotely their results for consultation before the visit. I have to spend a lot of time to thoroughly analyze them, and this in turn does not necessarily involve qualifying the patient for further treatment by me. And then the question arises: how to price such time-consuming advice? It is exactly the same consultation time as in a private practice. With such a situation this application probably will not cope.
And you, as Professor Artur Pupka, would you be able to work in Poland today, via such applications, or do you see too many barriers in this form?
AP: As for certain illnesses, at the initial stage I could give some advice by using this application. But to say more about a particular disease : about the treatment, the course of the disease, the consequences of the type of treatment, I have to see and examine the patient. At the same time talking about this first contact with the patient, I would be far from calling this stage a “diagnosis”. Let me present you a hypothetical situation in the field of vascular surgery – varicose veins. The patient sees that he has varicose veins and wonders what to do with them. At this stage I am able to give some advice and it can happen quite fast, even via such an application. However, if the treatment is to be carried out properly, the patient sooner or later should get to my surgery. First and foremost, ultrasound should be considered together with possible surgical intervention, minimal surgery, minimally invasive procedure, or abstinence from surgery – this happens when you have a patient in front of you. The problem with this application, in the case that I describe, would start when the patient writes “my leg hurts” that is very, very general. The lower limb can hurt for many reasons, for example, for 4 reasons 3 are trivial but this one is very serious.
And if such an application would become a “new profession”? ”? For example, for fresh graduates, who could thus make their first steps in the diagnosis?
AP: Is it possible in such an application to find an online doctor who will be an expert but lacks in experience?I don’t think so. Also through this platform the patient must have contact with a doctor who has the relevant experience, in the end there is not even an eye contact. On the other hand, it is often the case that the more experienced physician, the more doubtful the final diagnosis is. The power of empirical knowledge makes experienced, senior physicians not to make the quick and easy diagnosis that a patient would expect from a similar application. And filling such an online platform by physicians, this is certainly a big problem. Applications are designed to simplify our lives, but in the medical world there are not many cases that can be so easily solved. I am not talking about the legal issues of this online consultation here. This is also a complex problem to solve by people running such applications.
So how could such applications come in handy? Where do you see their best application?
AP: In my opinion, such solutions would be most useful to GPs who would not have had to charge the patients with additional fees for consultations because they would have been settled by the National Health Fund. Such use would result in much fewer people coming to them with really trivial problems. In turn, this would help specialists for patients who already benefit from their advice – they are known and were examined, and they need additional knowledge or brief advice from this particular doctor and that would be the quickest contact path. For example, in some of my practice in Lower Silesia I take patients only once a month. If the patient would like to know more from me in the meantime, this would be a great simplification for him. Especially if it would not cost him financially. On the other hand, it could be a good tool for me to inform my patient at the first contact if he should come to me with the problem or if he should go to another specialist.