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Mobile revolution brings changes to cardiology management
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More than ever, people today are connected by mobile technologies. Currently, 77% of Americans own smartphones, according to data from the Pew Research Center. The ever-increasing computing power and ability of smartphone technologies, wearable sensors and point-of-care diagnostic devices could transform cardiology, potentially leading to the better diagnosis, treatment and prevention of heart disease.
There has been “a huge explosion in terms of what mobile apps and mobile devices can now do,” Eric D. Peterson, MD, professor of medicine and director of the Duke Clinical Research Institute, told Cardiology Today. “The technical advances alone have been rather profound. Think about what you can now do with your cell phone, relative to what it could do 5 years ago.”
If these devices meet their potential, the effect could significantly alter management of heart diseases. Mobile health most certainly has the potential to increase cardiologists’ reach. U.S. citizens are generally unhealthy: 66% are overweight or obese, less than 1% of the population follows a healthy diet and most people are sedentary, according to Lora Burke, PhD, MPH, RN, professor of nursing and epidemiology at the University of Pittsburgh. Burke was also panel chair of an American Heart Association scientific statement on mobile health technologies that was released in late 2015. “With the use of mobile health tools, we could really reach a much larger number of people.”
However, the enthusiasm surrounding mobile health must be tempered, with the knowledge that there are obstacles to widespread adoption, such as the dearth of high-quality clinical trials testing these devices and apps, questionable data reliability and potential security issues.
“I feel a healthy dose of enthusiasm for where this field could go, but we still have a lot of work to do to actually show what’s safe and effective,” Seth S. Martin, MD, MHS, FACC, FAHA, assistant professor of medicine at Johns Hopkins University School of Medicine and a member of the Cardiology Today Editorial Board, said in an interview.
An impact in cardiology
Despite obstacles and limitations, the use of mobile health tools in cardiology is ramping up and has the potential to transform practice, especially for prevention of CVD, experts told Cardiology Today.
Tech companies such as Apple, Google and Intel are increasingly focused on health, bringing to bear their considerable resources.
Source: Duke Clinical Research Institute; reprinted with permission.
“The move toward health has been a notable one, and has been relatively recent,” Euan A. Ashley, MD, PhD, associate professor of medicine (cardiovascular) at Stanford University Medical Center, told Cardiology Today. “Many of us were excited that a company with the creativity and resources of Apple would focus on the health care market.”
The hope is that these companies will improve the level of functionality found in clinical mobile health devices.
“We’ve all been hopeful over the last few years that the advent of the emergence of the tech companies in health care would translate into some major changes,” Ashley said. (See Sidebar below for vital statistics on mobile health apps and their developers.)
That increased reach could transform diagnosis and even prevention of CVD.
“For the longest time, our health care system has been focused on acute care,” Raj M. Khandwalla, MD, MA, FACC, director of cardiovascular education at Cedars-Sinai Medical Care Foundation, said in an interview. “We’re good at taking care of diseases once they’re already established, but one of the areas where our health care system can improve in is the ability to prevent disease.”
Preventing CVD events using these mobile health tools is likely to result in cost reductions. “There is potential to use combinations of these technologies in a way to get ahead of presentation,” Ashley said. “The classic example is atrial fibrillation, where if you were able to pick it up early instead of waiting for someone to come in with a stroke, you could reduce a great deal of morbidity, mortality and health care costs.”
Current use
According to Khandwalla, mobile health devices fall into three categories.
- No. 1, there are the consumer-facing devices such as Apple Watch, Fitbit and Under Armour Band, which patients use to track their activity level, fitness level and sleep patterns as a means to improving their health.
- No. 2, there are the clinical-facing devices, which have diagnostic applications and have undergone the FDA approval process. One example is the AliveCor mobile ECG machine (AliveCor), which allows patients to monitor palpitations, according to Khandwalla.
- No. 3, there are the point-of-care mobile devices, such as portable ultrasound devices, which allow cardiologists to make diagnoses during a patient visit.
Source: Robert Levy Photography.
For example, “instead of ordering a formal ultrasound study, they have an ultrasound in their pocket, and can use that ultrasound to look at the heart, assess patients and make diagnoses,” said Khandwalla, a Cardiology Today Next Gen Innovator.
Mobile health consumers fall into three categories as well, Khandwalla added.
- The first group is the healthy people who use the consumer-facing devices because “they are interested in their athletic performance, and they want to use health care trackers to boost and optimize their athletic performance,” he said.
- The second group wants to make significant behavior changes, and needs a tool to help them achieve that goal. “This group of patients can use activity trackers to quantify their level of activity and then slowly make improvements to be able to meet their health care goals,” Khandwalla said.
- The third group is those who have survived a traumatic event, and now want to make drastic lifestyle changes. “I’ve seen a lot of patients in my practice who have had MI or needed a stent and who now see these events as a real turning point in their lives,” Khandwalla said. “The consumer products can be one part of a multipronged approach to be able to make significant changes in their lives.”
Benefits for providers, patients
Most mobile health devices, whether consumer- or clinician-facing, offer benefits, experts told Cardiology Today.
For patients, the consumer wearable devices force them to develop greater behavior awareness, according to Burke. Many people are often shocked to learn exactly how much food they consume or how much time they spend in sedentary activity each day. Moreover, mobile health devices can allow them to see the changes they have made. “They can see the effects of their behaviors by this tracking,” Burke said.
For cardiologists, mobile health devices allow better monitoring of common cardiac problems, such as AF. With a mobile ECG machine, patients can record their symptoms at the time they have them and send them directly to their cardiologists. “The beauty of the mobile ECG is that you can use it right at the time you have [an irregular heartbeat] and then send the tracing in,” Burke said.
In fact, mobile health may allow providers to bring health care to a larger population. “This actually may provide ways in which we can reach communities we traditionally haven’t been able to reach because of access issues to high-quality health care or the ability to take time off work,” Peterson said. He was co-author of a 2016 review article published in the Journal of the American Heart Association on the potential role of mobile health in the early diagnosis and prevention of CVD.
An area with tremendous potential for mobile health is the addition of some of these data to electronic health records, which will allow physicians to see more clearly how their patients behave, according to Burke. However, she said, “We’re not there yet.”
Before these benefits can be fully realized, though, stronger evidence is needed, as some devices and apps have failed to perform as promised (see Sidebar below).
Obstacles to adoption
Maintaining patient privacy while using mobile health devices is paramount. Appropriate security measures continue to be assessed.
“Mobile health is an emerging field,” Khandwalla said. “I don’t think a lot of these issues have been completely sorted out. We don’t know how the data from these devices can be potentially abused.”
Another obstacle is sustaining patient engagement: Many patients are enthusiastic about using mobile health tools in the beginning, but their enthusiasm wanes after a few months.
A challenge, Burke said, is “how to get people engaged and how to keep them engaged in using these products, with the goal of changing behavior and leading to a reduction in CV risk.”
With the doubling of smartphone ownership since 2011, the digital divide, at least from a socioeconomic perspective, has largely closed.
“A growing percentage of almost all adults have access to some sort of cellphones, with many now having smartphones,” Peterson said. “The gap in access to these technologies isn’t as big as it used to be.”
However, an age-related digital divide may still be an issue, though Burke said it is decreasing each year.
“The digital divide is greater related to age, rather than socioeconomics,” Peterson said. Having grown up with technology, people aged in their 20s are more attuned to technological advances.
Currently, payers do not reimburse for consumer-facing devices, and data are needed to help clear the reimbursement hurdle. “The biggest challenge is demonstrating to the payer that we’re ultimately reducing health care costs,” Burke said. “This is where we need the data, to demonstrate that people who use these devices are doing better in terms of following their diet, being more active, keeping their BP controlled, and so on.”
Mobile health device developers are also encouraged to solicit more input from clinicians and patients. “Many of these apps are developed without clinician input or without end-user input,” Burke said. Typically, industry is “anxious to get a product to market, while we, on the academic side, are more likely to say, ‘Well, no, let’s evaluate it.’ We want people to use it, to give us feedback on what’s good and what’s bad about it. Research and industry have not come together as well as they should have yet.”
A look to the future
Although mobile health devices have wide potential to yield a lot of data, not all the information is useful. Researchers must determine how to combine these wearable sensors with clinical decision support tools to analyze and translate the complex data streams into useful, actionable recommendations for clinicians, according to Khandwalla.
More research is needed to allow physicians to use these devices to target individual physiology, according to Khandwalla. “Our hope is that we can use these devices to actually personalize care. One way we could do so would be using wearable sensors to test the efficacy of pharmaceuticals or procedures on individuals. We could combine these data with personal genomic information and perhaps discover patterns in how different patients respond to different therapies. Eventually the goal would be to create a data-rich tool that guides personalized treatment.
“Another way we could use sensors would be to remotely manage large populations of patients,” Khandwalla said. “Wearable or implanted sensors could help cardiologists follow thousands of patients from their office. These wearable sensors could one day alert cardiologists of the patients that need to be seen in the clinic and decrease the number of unnecessary physician visits.
“Eventually, what we will see is that cardiologists will be able to remotely manage large populations of patients,” Khandwalla said. “Patients will have those implanted and wearable sensors within them and will have one cardiologist following thousands of patients. These wearable sensors could one day alert cardiologists of the patients that need to be seen in the clinic and reassure cardiologists of patients that can be followed remotely using these sensors.”
Eventually, these tools could increase the scope of and accelerate the results of clinical trials. “That’s the hope,” Peterson said. “The challenge right now is that we have limited evidence that they can deliver on these promises. We need these sensors and devices to be rigorously tested and evaluated so they’ll be accepted by the FDA, clinicians and payers. But the challenge to researchers is to find a way to make these evaluations affordable to small tech start-ups. We, the research community need to start experimenting with new models of how we would do research effectively in the routine practice of medicine.”
In health care, mobile health may eventually facilitate change on a grand scale. “If we’re going to make huge changes on a national or international scale and do population health, exploiting mobile technology is one means of reaching lots of people in various ways,” Peterson said. “Second, if you look at trends, we moved from hospital to clinic, and now we’re thinking about moving from clinics to home; it’s just a gradual extension.” – by Colleen Owens
- References:
- Burke LE, et al. Circulation. 2015;doi:10.1161/CIR.0000000000000232.
- Eapen ZJ, et al. J Am Heart Assoc. 2016;doi:10.1161/JAHA.115.003119.
- Pew Research Center. Mobile fact sheet. Available at: www.pewinternet.org/fact-sheet/mobile/. Accessed April 4, 2017.
- For more information:
- Euan A. Ashley, MD, PhD, can be reached at Stanford University, Cardiovascular Medicine, 300 Pasteur Drive, Room A265, MC 5319, Stanford, CA 94305; email: euan@stanford.edu.
- Lora Burke, PhD, MPH, RN, can be reached at the University of Pittsburgh, School of Nursing, 415 Victoria Building, 3500 Victoria St., Pittsburgh, PA 15261; email: lbu100@pitt.edu.
- Raj M. Khandwalla, MD, MA, FACC, can be reached at Cedars-Sinai, 250 N. Robertson Blvd., Suite #403, Beverly Hills, CA 90211; email: raj.khandwalla@cshs.org.
- Seth S. Martin, MD, MHS, FACC, FAHA, can be reached at Johns Hopkins School of Medicine, Division of Cardiology, 600 N. Wolfe St., Carnegie 591, Baltimore, MD 21287; email: smart100@jhmi.edu.
- Eric D. Peterson, MD, can be reached at Duke University School of Medicine, 2400 Pratt St., Suite 7009, Durham, NC 27705; email: eric.peterson@duke.edu.
Disclosures: Ashley, Burke and Peterson report no relevant financial disclosures. Khandwalla reports chairing the steering committee for the AWAKE-HF trial sponsored by Novartis and conducting a Novartis-funded trial on wearable sensors. Martin reports receiving research support from Apple and Google.