Virtual Medicine: A Red Herring? Ezekiel J. Emanuel, MD, PhD

Thank you for joining us
today for Dr. Zeke Emanuel’s webinar called, Virtual
Medicine– a Red Herring. I’m Caitlin O’Neil,
program manager for online education
in the University of Pennsylvania’s
department of Medical Ethics and Health Policy. Dr. Emanuel is chair of the
Department of Medical Ethics and Health Policy and Vice
Provost for Global Initiatives, as well as holding many roles of
influence in health care today. And now, please welcome
Dr. Zeke Emanuel. Fantastic. So let me start. And the first thing I
was going to do was– I was in the midst of
defining a red herring. One definition is that a red
herring is a herring that turns red when it gets smoked. That’s not the definition
we’re interested in. The definition
we’re interested in is one that comes from a
British member of Parliament and a pamphleteer and
radical politician, who said that he used a red
herring to divert the public, or they’re being diverted. And that comes from a
notion that the red herring would divert dogs chasing a
hare or a fox on the hunt. So a red herring is a
seemingly plausible, though ultimately irrelevant,
diversionary question or , suggestion which may be
intentional or unintentional. And I do think that a lot of
stuff around virtual medicine and all it’s going to do to fix
the American health care system is a bit of a red
herring diverting us from the real issue. So let’s go to Eric Topol,
who’s a professor at Scripps in San Diego. And he says, “Over
the past decade, smartphones have
radically changed many aspects of
our everyday lives, from banking to shopping
to entertainment. Medicine is next… Just as the printing press
democratized information, the medicalized smartphone
will democratize health care. Anywhere you can
get a mobile signal, you’ll have new ways to
practice data-driven medicine. Patients won’t
just be empowered; they’ll be emancipated.” Well, is that true? What do we mean by
virtual medicine? Let’s begin. I think it’s any use of big
data, deep analytics, AI machine learning,
and/or wireless and wearable technologies
that, in some combination, are supposed to lead to
improvements in the diagnosis and/or the treatment
of patients. That’s what we typically
mean by virtual medicine. Well, the question is, is
it going to actually work? To give you the
bottom line, now I think that it’s not
substantially involved in the physician-patient
relationship. When it does get
involved, it actually doesn’t work particularly well. Big virtual medicine can work
mainly in the background. You can have data
aggregating [INAUDIBLE] that can help with the health team. You can coordinate
health team activity. You can actually evaluate the
performance of health teams. But I think the
fundamental diet, the physician-patient
relationship– virtual medicine is not likely to do a
lot in that context. Why do I say that? Well, let’s just go
to a few studies that have recently been published. This is a 2016 JAMA
internal medicine study, where, in California, they
randomized 1,500 patients with congestive heart
failure into two groups. One group got usual care. One group got remote
wireless monitoring via blood pressure cuffs,
a wireless scale, symptom management on their iPhone. All went to a nurse. They got health coaching
phone calls with a nurse, and if a nurse found anything
unusual would report it. And what was the result
of said intervention? Well, basically no change
in 30-day mortality, and– or 30-day readmission rate and
no change on 180-day mortality. It was basically
a negative study. The remote monitoring with
wireless broad pressure cuffs and scales and symptom
management did not work. Then there’s another
study, and that’s a 2017 study, again
in JAMA IM, trying to improve patient adherence
to their drug prescriptions. CVS Caremark randomized
over 50,000 patients into three different arms. One had a pill box with
strips with toggles; that is, you opened
up every day’s pills. Another had a digital timer cap. If you didn’t open the pill
cap by, say, 11 o’clock, it went off, alerted people. And then a regular
standard pill bottle– you unscrewed the top
and took your pills. There was no difference
in medication adherence in the three arms. As a matter of fact, the
old-style pill bottle with toggles was
probably the best, although not really
statistically or clinically significant. Next study showed that– in 2016, this study looked
at using activity trackers, among other
interventions, on patients who were obese to
decrease their obesity. Participants were placed
on low-calorie diets, prescribed increased
physical activity, and had group
counseling sessions. And one group had an
activity tracker that would hopefully motivate them. At six months, half the
group began with their diet and activity through
a website, and half were given wearable devices to
track their diet and activity. Those who used a
wearable tech actually lost less weight than the people
who had traditional tracking. So again, another case where
virtual medicine doesn’t seem to play. And finally, there’s
a 2016 Lancet study investigated whether
the use of activity trackers alone, or
with combination with various
monetary incentives, led young people, 18
to 34, to increase their physical activity or
improve other health outcomes. The results, shown
on the next slide, were that after 12 months, there
was no evidence of improvement in health outcomes. Those with financial
incentives did improve their physical activity. But when you took away
the financial incentive but left the Fitbit,
there was no increase in physical activity. In fact, this was
another case of where the actual change
in behavior was because of incentives, not
because of the wireless Fitbit device. So what do we learn from this? As one of the
study leaders said, “These devices have
some really cool tech, but how do you use them in
a way that helps people? Overall, it doesn’t
look like assigning someone wearable technology
will make that big of a health difference.” And I think that is the bottom
line of almost every study that we’ve had now. You cannot get people to
either take their medication, change their exercise, actually
prevent hospital readmissions or mortality with
congestive heart failure. There are very few
studies done in a rigorous,
peer-reviewed way that show any change by simply
using wireless devices or virtual medicine. Why has virtual medicine failed? Well, I think the reason is
that the big problem facing medical care is behavior change
of physicians and patients. Virtual medicine doesn’t lead
to behavior change by itself. Remember, in the tech
world, what you really want to do with all
that data analytics, that AI, that machine learning,
all of these wireless things, is sell people things. Right? You want to crunch the numbers,
find out what they like, and try to sell them. In medicine, you have
a bigger challenge, which is we want to
change their behaviors. We want to make people
eat differently, exercise, take their pills, et cetera. That’s harder, and that’s
not like advertising. I think virtual
medicine is never going to replace a
physician-patient relationship. It might supplement it. And it works best
in the background, informing and improving
physician actions. We have seen some
places where it works. Take Kaiser Mid-Atlantic. It’s a pioneer of
virtual medicine, and yet only a small fraction
of its physician visits are conducted by
video, about 1%. And so I think it can
supplement, but not replace, face-to-face clinician-patient
interactions. And by the way, it positively
impacts convenience more than actually saving money,
in the case of Kaiser. One place where it
has worked is when you can actually use it
in a sort of low-tech, not high-tech way. This is the vice president of
Iora Health, a primary care startup in the
United States, and he says, “The implementation of
most electronic guidelines will cost a lot of money, and
it will cause a lot of pain. And I think, personally,
that video chat”– telemedicine– “is just
a fancy phone call. But we find that the best
use of IT, by a wide margin, is text messaging
for follow-up care.” Did the patient get better? Did their cold go away? Did their urinary tract
infection go away? Well, text messaging is
hardly big, high-tech virtual medicine. So where do I think virtual
medicine might work? Well, probably its
biggest place is in rural health, where it’s hard
to get doctors and other health care providers to work. Various other places it
might work are on tele-ICUs– we’ll talk about
that in a second– behavioral health
situations, where patients can talk
to a therapist; MD-MD consultations–
taking a picture of a skin lesion or such thing and
getting the dermatologist to interpret it; follow-up
care, as we mentioned, with chronic conditions,
mostly by texting; and minor care resolutions,
where patients have questions. Banner Health is a good
example of tele-ICU program, where they’ve used Phillips’s
tele-ICU solutions. The program employs
video cameras with audio hookup
in every ICU room, and the cameras
stream real-time data, like blood pressure,
heart rate, to an off-site tele-intensivist,
who monitors the entire ICU. In the past 10
years, the program has expanded to provide
services at 26 different Banner facilities. They’ve had some
impressive results. They’ve actually saved
a number of lives, by their own calculation. They’ve had 33,000 fewer ICU
days, 47,000 fewer hospital days, and saved
almost $90 million by saving lives and reducing
intensive care unit days. Another place I think you might
see it is in mental illness. Lots of people in
the United States have depression,
anxiety disorder, and we know that we have an
undersupply of psychiatrists, as well as other behavioral
health specialists. There are only
28,000 psychiatrists in the United States
for 325 million people, only about 100,000 clinical
health psychologists. So we need people to
do behavioral health. There are companies in this
space that are trying this. Quartet Health, a group
with which I am affiliated, has a virtual
collaborative care model, where technology has been
used to diagnose patients– they give them surveys– and treat patients with
comorbid health issues. 40% to 50% of
Quartet patients are referred to a behavioral
health specialist. They’re seen within 10
to 14 days, as opposed to two or three months
in the usual case, and those with more
urgent health problems are seen more rapidly. The actual rate of no-shows
at these appointments is much less, 15% compared
to a national average in comorbid conditions of 40%. So this is a case of
where online connecting between doctors and patients
may work, but it’s connecting. Some of the therapy is online,
but a lot of the therapy is in person. Bob Wachter, who is Chairman
of Medicine at UCSF, has written, I
think, very elegantly about virtual medicine. And he says, “The simple
narrative of our age– that computers improve the
performance of every industry they touch– turns out to have
been magical thinking when it comes to health care. In our sliver of
the world, we’re learning computers make
some things better, some things worse, but
they do change everything.” And I think the idea
of heavily investing in virtual medicine
on the notion that it’s really going to
radically transform health care is probably a mistake. We should focus more on
computers helping doctors get information to
manage patients, unless I’m putting
computers in IT and AI in between doctors and patients. So that’s all I have. I want to remind
people that we have courses available for people
that go into these topics more in-depth. I’ll be teaching a
course on transforming the American health care
system and how we can actually use different techniques for
it soon, beginning on June 1st. But if you have questions,
please ask them now. So one question is, how do you
measure effectiveness and cost? Well, you can measure
effectiveness by [INAUDIBLE].. –how do you change
patient behavior? As I mentioned, in one of those
studies in congestive heart failure, by giving people
wireless technologies, wireless blood pressure
cuffs, wireless scales. Do we actually change
their health [INAUDIBLE]?? Do we change their
30-day readmission rate? Do we change their
six-month mortality rate, with congestive heart failure? That is a traditional
endpoint, but we haven’t been able to achieve that at all. A second measure
might be cost savings. If we substitute online
interactions between the doctor and patient, do
we actually reduce the number of in-person
visits, and does it reduce the total costs of care? So far, we haven’t seen that. In the case of
tele-ICUs, by reducing the number of
hospital days patients spend in the intensive care
unit and in the hospital, you can actually demonstrate
some cost savings. So those are some of the
more traditional methods by which you might measure the
outcome of virtual medicine interventions. The one, I think,
important point that I would emphasize
now is the importance of trying to use telemedicine
in the context of rural health. No country– not Australia,
not Canada, not Norway, not the United States–
has really solved the problem of getting more
physicians, more health care professionals, in rural areas. And telemedicine, by
connecting rural clinics or rural doctors, especially
towards specialist care, can help. It’s a way of getting specialist
consultations in an area where there aren’t a
lot of specialists And I think this is probably
its biggest and most effective interaction, and that’s
because of a dearth of doctors. Does forced patient involvement
requiring a patient response improve adherence? I don’t know that we
force patient involvement. After all, if patients
don’t text you back or don’t take an
action, it’s unclear what the consequences,
the negative consequences, are going to be for the patient. You wouldn’t want to say,
lock the pill bottle so they couldn’t get the pills
if they didn’t respond to some kind of question. It’s not clear that
you can actually force patients to do certain
things, like get on that scale or take their blood pressure. So exactly what it means
to force patient responses in this context is
a bit unclear to me. Somebody asks, is
there any indication that telehealth has
different impacts for different generations, like
baby boomers or millennials? Well, there was an interesting
study in Singapore, a very wired place,
trying to get young people to increase their
physical activity, and again, randomized
them to wireless Fitbits versus no high-tech
interventions, no Fitbit. And even though they were
younger, more tech-savvy, you would think,
than older people, did not have a big effect. It had no effect, actually,
no statistically significant effect, in terms of increasing
physical activity or decreasing food consumption. Now, you might say,
well, maybe when that generation grows older
and has more serious health problems, they’ll be more
technologically savvy. That’s always possible. But remember, right now, $0.86
of every dollar for people with chronic conditions–
most of those people, the vast majority of
those people, are older, and at least for the
next few decades, we’re going to have to deal
with that older generation. And if they’re not tech-savvy–
they don’t interact with tech all the time– that’s the generation we have to
figure out how to connect with and how to change
their behaviors. And as I said, so far we
have not a lot of evidence that today, behaviors,
even among younger people, change with technology,
wireless technology and such. Somebody asks, is
there any evidence of increased patient follow-up
if appointments can be virtual rather than physical? Well, as the [INAUDIBLE]
said, one of the problems is that some of the technology
doesn’t work as we want it. I have not seen data
about the no-show rate on virtual interactions. I will tell you,
one of the problems of virtual interactions
for the doctor is if they end up running
behind a little bit. [INAUDIBLE] can’t
[? make it ?] exactly at the start of 1 o’clock,
it doesn’t work so well for patients. And another problem
that has been [INAUDIBLE] by trying to have
more appointments or more emergency room calls
off hours virtually is that its convenience
factor actually encourages a lot of use, not
all of which is urgent care. It just might be more
convenient for the mother to do it at 8:30. Her kids might like
to see the doctor. Now, that might be helpful
from a convenience factor, but it’s not clear that it’s
actually addressing real health needs that can’t wait
to some other time or that won’t just simply go
away without the convenience. So there may be important
convenience issues, but there could also be
overuse of the technology when it’s made so easy. Somebody asks, do you
think that the situation might be different in pediatrics
than with adult health care? Again, no evidence
that that is the case, and I would remain skeptical. I do think it does
help in that it may be more convenient,
especially for a parent who has multiple kids, rather
than going to a physician’s office or an urgent care
center or the emergency room. But how much that also
might lead to overuse is, I think, something
we need to evaluate. And the second thing is how
much that might encourage use for non-urgent problems that,
say, resolve by the morning, is another important question. Somebody asks, is there evidence
of increased patient follow-up if appointments can be
virtual rather than physical? Again, I have never
seen a consistent drop. As I mentioned in the Quartet,
with behavioral health using online connection, with the
patient, online scheduling, the no-show rate for
in-person interaction with the behavioral
health specialist has dropped from 40% to 15%. But there’s a lot
of support that goes into that,
such as reminders and other things which mostly
are not very high-tech. They tend to be text
messaging to a telephone. You don’t need lots
of virtual medicine for that text messaging. So I do think we
need to differentiate using simple stuff,
like text messaging, from more complicated artificial
intelligence, machine learning, wearables, and wireless tech. Again, if it’s all text
messaging, reminding you of the appointment, getting
you an Uber or Lyft, that’s hardly high-tech
virtual medicine. Are there any current
or ongoing studies about virtual
medicine, and what’s the level of interest
or funding for it? I would say that there’s
a substantial amount of funding for various different
virtual medicine interactions. As you might imagine, a lot
of the venture capitalists who’ve grown up around
Silicon Valley and think tech solves a lot of things have
heavily invested in this space. Some are trying different
interactions, via PBMs, to try to get patients to
renew their medications, ask questions about
side effects, via– and have chat bots
interact with patients to provide them information,
as just one example. I do think this is a case
of where there remains a lot of interest, but there
have not been proven methods to actually solve problems. Another area where there turns
out to be substantial interest is to try to use
some platforms to get patients information
about cheaper facilities to use, cheaper labs to
go to, cheaper imaging facilities, as an
effort to save time and to connect with patients at
the point of decision-making. I think these are all promising,
but again, the difference between promising and actually
effective and cost-reducing or quality-improving
is a big gap, and I think we need a
lot more rigorous study. And I don’t think
just around the corner is going to be a big virtual
medicine solution to a problem. And I would just remind
you of, for example, Apple has this great addition to its
Apple Watch about detecting AFib and it turns out not to
be very good at detecting AFib and should not be used
for patients who have AFib to monitor themselves. It’s another case of
where people thought there’d be a great
intervention, we could determine if patients
are popping into AFib or not, and it turns out to be
mostly smoke and not a lot of real
medicine intervention that is something
we could rely on. So that’s why I entitled this
talk Virtual Medicine– a Red Herring. I think too much focus
on this is taking us away from the key issues
facing medicine, which are behavioral
change, changing how patients and doctors
actually behave, whether it’s exercise or diet, or
medication adherence, or adherence to
physical therapy. And that’s a bigger
challenge than is going to be solved just
by aggregating data, using more wireless or
wearable technology. Thank you very much,
and let me remind you, you will be receiving
a coupon if you want to take additional, more
in-depth courses than just can be offered in a
quick half hour webinar.

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