Virtual Visits and Wearable Technology Meet Pediatrics

Hansa Bhargava, MD; Daniel Kraft, MD


March 23, 2016

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Hansa Bhargava, MD: Hi. I am Dr Hansa Bhargava, medical editor at WebMD and medical advisor for Medscape. We are talking about pediatric trends with Dr Daniel Kraft. Daniel, can you tell us a little bit about yourself?

Daniel Kraft, MD: I am trained as a pediatrician and in internal medicine, and I also specialize in hematology, oncology, and bone marrow transplantation. I spend part of my time looking at the future of healthcare as chair of medicine at Singularity University, and chairing a program called Exponential Medicine, where we look at how technology is integrating to improve healthcare.

Dr Bhargava: We will be discussing emerging trends in pediatrics, so let's start with the definition of the doctor's visit. The public is eager for options other than the traditional doctor's visit, but pediatricians have been reluctant to embrace these virtual visits. But here is an interesting fact: A large healthcare insurance company just signed up to cover up to 20 million video visits by 2016. Do you think that the time for virtual visits has arrived?

Dr Kraft: I think putting them in two buckets is probably a false dichotomy. This era of telehealth, or virtual visits, will combine with the onsite visit. Follow-up can be done by smart digital touchpoints—for instance, by sending a kid home with otitis media and then using some of these new connected devices, like the CellScope® [CellScope, Inc; San Francisco, California], to do a virtual ear exam instead of returning to the doctor's office for the follow-up. All sorts of exams can be done at home with wearable devices, even to point-of-care lab tests. I think that as the incentives change and reimbursement shifts to reward e-visits, email, etc, we are going to see this integration of healthcare in the doctor's office, in the outpatient setting, in the clinic, and elsewhere.

Dr Bhargava: Why do you think some physicians are reluctant to embrace this new technology?

Dr Kraft: We are entering this new era of connected mobile health and digital health. The reluctance often is: How do you work this into your practice? Digital ear exams, for example, might not have a billing code. In this era of outcomes-based medicine and value-based care, the primary care physician may get a bonus at the end of the year for having diabetic patients attain better blood glucose control or having hypertension patients achieve better numbers; therefore, you might prescribe them a connected blood pressure cuff, or connected scales, or wearable devices to track their progress and to give them mobile guidance. So, aligning incentives for different practices is shifting, and I would encourage any clinician, pediatrician, or otherwise to start embracing and piloting some of these technologies. An US Food and Drug Administration (FDA)-approved step counter isn't needed to track a child with obesity issues in order to get insights into their total number of steps or their sleep patterns. This is the time for clinicians to be innovators rather than waiting for regulatory approvals.

Dr Bhargava: As a parent, I think virtual visits are easier. But do you think we can still maintain privacy and HIPAA standards, and what about the legal ramifications of sending emails and texts to patients?

Dr Kraft: Sometimes, technology ramps up much faster than our friends at the regulatory agencies or the payers can sort out, and there are well-meaning (but old) regulations like HIPAA, which in my view has sometimes gone a bit overboard. There are whole armies of folks doing HIPAA management, whereas all we want to do as patients is share data. This idea of the patient as a data donor, the participatory patient, is emerging, along with a clinician and an EMR that share information between each other—all with the potential to amplify and speed up everything, from clinical trials to smart medication safety management. So I think email is not an old technology, but it is new in the clinical realm because, in many cases, clinicians starting to be reimbursed for it. So I think we need to be informed about our regulations. We also need to help our friends at the FDA, the payers, and other groups to start incentivizing the use of technology. It is a challenging area—for example, how do you regulate an app? How do you regulate a connected medical device? But we have an opportunity to look at where technology is taking us and help shape regulations and the issue of reimbursement.

Dr Bhargava: There is a lot of technology that exists to help us work with privacy screens. One EMR that I worked with is incorporating high-quality images, so that we can actually take pictures of the patients. But they did let the providers and doctors know that they would have to download AirWatch® (vmware; Atlanta, Georgia). Is that an appropriate way to guard patient privacy, by requiring physicians to sign up for something like AirWatch, where the software vendor has the capacity to delete everything on your phone?

Dr Kraft: We are in an era now with the choice of many devices or apps, whether it be AirWatch or something else. We are starting to move away from this era of sick care, which has been intermittent and reactive. We get intermittent pieces of data, either faxed or submitted in person, and then we react. In the past, we waited for the acute asthma attack or lump to be discovered at an advanced stage. But now, with these smart connected technologies and apps, we want them to be integrated. You don't want to log into five different applications; rather, you want to have it be part of your standard workflow, so a lot of technologies are needed here. It needs to be part of the workflow of the clinician or nurse, and we are seeing things like Apple's HealthKit now starting to integrate your scale, glucometer, blood pressure kit, steps, and fitness apps, with all of these devices flowing back to you to a single location. So, part of the future of pediatrics will be prescribing your patient a wearable device, or a scale, or a neonatal monitor, and that data will flow back to you in smart ways, and you won't have to monitor it continuously. We need to develop smart data layers in addition to machine learning, or maybe artificial intelligence, to create actions, like pinging a patient to come in early before their condition is exacerbated, or nudge them if they are not adhering to treatment. So the trick is integrating these massive amounts of big data and finding a way to make it actionable for the clinician, consumer, caregiver, and parent while not being overwhelmed by unconnected data.

A Role for Wearable Technology?

Dr Bhargava: Another big technology trend is related to wearable technology. These are fitness devices that track steps, heartrate, and sleep. We are now seeing kids wearing Fitbits and Apple watches. Do you think there should be rules for wearable technology for kids?

Dr Kraft: Absolutely. I think we are in this era—it is often called the quantified self, which is the ability to measure your steps and sleep, for instance—but we are also moving into this era of quantified health. As I mentioned earlier, these data are going to start flowing back to your pediatrician or public health officer. These things can be helpful. Now is the early era of just tracking your steps or basic sleep data, but these data will become more complex. We are going to eventually monitor digital exhaust off of our bodies, or monitored by our Wi-Fi, or our connected homes, which will provide terabytes of data per patient per day. The trick is, what do we do with that? For example, we can use step counters as a way to create rewards for a child who might have weight issues, or is sitting on the couch playing video games, to get insights into how many steps they are doing. They might get rewarded with more screen time if they are hitting their 10,000 steps. We can also use this technology to get insight into an adolescent who doesn't get enough sleep, which is important for healthy development. So, we are in the early era of these sorts of step counters. There are also wearable devices for babies that can go on their ankles, or wearable onesies that can track a child and enable the healthcare provider to send them home from the NICU or PICU earlier. I want to think beyond the sort of simple step counter and see how these devices can improve patient care. You might even be prescribing a wearable device for tracking asthma or your respiratory status, and there are some that can detect seizures early. So let's think beyond the step counter as we start to consider this idea of wearables and connected devices in the future.

Dr Bhargava: It is interesting that you said incentives help, and there has been a lot of research to show that text reminders, or any kind of reminder, helps the patient be more compliant. There is a new bracelet for kids called the UNICEF Kid Power band that tracks the child's points, and a certain number of points can translate to the delivery of nutrition packets to other kids in the world who are nutritionally deficient. But I think what might be on a lot of clinicians' minds are concerns about FDA approval. Does a device have the research data to support the accuracy of the data captured by the device, and if not, then what do we do with the false positives, false negatives, or other inaccurate data?

Dr Kraft: I think we all want some sort of gold standard that this is the exact number of measured steps, or exact blood pressure, or blood glucose. There are consumer devices that are going to be moving towards FDA approval, and some of them already are. But in many cases, particularly for behavior modification, you don't need an FDA-approved step counter. We can use different profiles to modify behavior. Not everyone wants points, badges, or dollar incentives. We need to understand each individual to better understand the triggers that will modify behavior, and to fine-tune the nudges so that it is part of their everyday health. It used to be that you went to your clinician or pediatrician and they would tell you what to do. In this new era of the empowered patient, the new drug is you—the empowered individual who is a partner or a copilot with their clinician, rather than just waiting for them to tell you what to do. These integrated behavioral change–type applications, for both prevention and management of acute and chronic disease, can be a big game changer.

Dr Bhargava: You are saying that the benefits of this technology can help us improve patient compliance and move these changes forward, so we need to focus on the benefits more than the question of whether the FDA is keeping up with these changes.

Dr Kraft: It is one thing for an app to track your basic steps or diet, but it is another matter if it is an app that connects to your glucometer and tells you how much insulin to take. So the FDA is on top of new guidance for regulating certain kinds of apps and connected devices, which is this idea of digital therapeutics. I may not prescribe you just a drug anymore; it is going to come with a wearable device and an app that helps track your adherence and will nudge you if required. This is the advent of coaching: You could have a personal coach connected through your smartphone, and soon there will be artificial intelligence (AI) versions of these. Some apps today will help track and nudge you in intuitive and fun futuristic ways. While the FDA element is important, we don't need to be completely stuck on that for certain applications. In this era, where we can start to measure our health, we are learning what is important to measure. We haven't had this digital data from non-healthcare settings previously. Rather, it used to only be available in the ICU, ER, or the ward. For instance, we will learn that a temperature of 98.6º F is not always normal.

We are entering an era of the empowered patient and consumer. I have been an advisor for the XPrize® Foundation. One competition supported by XPrize was to develop a home-based version of a biological monitor, and one that is already in development from a company called Scanadu is a home-based vital sign kit that tracks heart rate and temperature, and calculates blood pressure and oxygen saturation. That is going to enable a parent who has a kid with asthma, for example, or is coming down with influenza, to detect those conditions early, be proactive, and connect that data to the pediatrician or healthcare team. We are going to move well beyond the digital thermometer to make sense of this technology in ongoing and proactive ways. As we incentivize the healthcare system to keep us healthy, as opposed to the sick care equation where we get paid to see more and more sick kids and perform new procedures, we will see these technologies take off.

Dr Bhargava: For example, the pediatrician talking to a patient at 2 AM who is trying to figure out if they need to go to the ER could benefit from that pulse oximeter, which could provide them with the data that they need to assist in decision-making, right?

Dr Kraft: Sure. It is not going to take one snapshot. It may be tracking that child over time and be layered in, as this company is doing with AI from IBM Watson, to start parsing this information, using machine learning and crowdsourcing from hundreds or thousands of patients. You may know whether a particular neighborhood has an influenza outbreak and be able to use that to start triage. The clinician does not want to get overwhelmed by this data; therefore, we are going to need to layer smart analytics and not only AI, but also IA—intelligence augmentation—to help us do smarter, cost-effective workups and provide more personalized and precise therapeutics when we have to make a decision about a particular therapy.

Dr Bhargava: That sounds very interesting, and it sure seems like our world is changing. Is there anything else you would like to add?

Dr Kraft: There is a famous quote by William Gibson: "The future is already here—it's just not evenly distributed." The technology is not evenly distributed, and I think it is up to clinicians everywhere to start creating the future, not waiting for it. So there is a whole slew of devices you can buy online or elsewhere, including connected blood pressure cuffs, scales, and glucometers that you can start using with your patients today. Maybe those apps don't quite work with your healthcare EMR today, but soon they will. Start being on the front line. Start finding solutions to your problems using some of these new smart, connected tools to help engage you, your patients, and their families, and to improve outcomes and lower costs.

Dr Bhargava: Sounds like change is here; we just need to get on board. Thank you very much, Dr Kraft.


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