Hidden costs are bad for business

Since we live in an old house, I've hired a lot of contractors in my time. The first step, of course, is getting an estimate for the work; the second step (after I recover from sticker shock) is discussing what to add or drop from the estimate to meet my needs and my budget. I would never hire a contractor and say "just bill me when it's done." I need to know how much it will cost me, and the estimate needs to be correct.

Alas, this is not the model that some doctors follow. I was reminded of this recently when my daughter had a minor medical problem. I asked my pediatrician to take a look, but her office referred me to a specialist instead. At the first visit with the specialist, he wrote a prescription for a medication that cost $200 (I found out later at the pharmacy), then went on to bill us $191 (after insurance kicked in) for the visit. When I called his office requesting a cheaper medication option, he recommended using a $20 over-the-counter treatment off-label.

At the follow-up visit, the receptionist asked me whether I'd like to pay the bill for the first visit. No I would not, I said, because we had just received the bill a few days earlier and had not yet sat down to pay our bills for the month. If my ire was apparent, at least my daughter learned a valuable lesson: how to say no.

During the five-minute follow-up visit, I told the specialist that I was not comfortable using a treatment off-label, ignoring the bold warnings on the box. I stopped the treatment. He insisted that the off-label treatment he recommended was safe, then billed us another $191 for his time.

The saga ended at last when we saw my daughter's pediatrician for a yearly checkup a few weeks later. She recommended an alternative, $15 on-label over-the-counter treatment, which worked like a charm. 

Ultimately, we were out $400 - more than we budget for out-of-pocket health care costs each month -  to treat a problem that could be cured for $15. Had I known what it would cost at the outset, I would have held out for a (much cheaper) appointment with my pediatrician, or gone online to the fabulous Mayo Clinic Health Information site to diagnose and treat it myself.

Health care is a business, and we are the customers. Yet it doesn't always feel that way. The specialist never told me what the medication or the visits might cost me, or asked whether I was willing to use a treatment off-label, or asked my daughter how she felt about the treatment.

He made good money off of my family. But, like any business that doesn't put customers first, he lost any potential long-term revenue from us. We won't be back.

How safe is that health app? A Q&A with Happtique (Part II)

Today, I discuss who is responsible for keeping health apps from harming you, in Part II of my Q&A with Paul Nerger, Senior Technology Advisor for the mobile health application management company Happtique. (Part I explained who uses and develops health apps).

How are health apps regulated to ensure that they are safe and accurate (both stand-alone apps and those that connect to a medical device)?

There are guidelines that have been proposed by the Food and Drug Administration (FDA) for the approval of some apps; we estimate that this will be no more than 20% of the apps that are out there. These will be classified as Type I (non-invasive), Type II (semi-invasive), and Type III (invasive), and each has its own approval criteria. Type I is a self registration while the other categories require clinical trials to prove that they do no harm and are effective. [Information about how the FDA defines mobile medical applications is available online.]

But what about the other 80%? That is what our customers have been asking us. If there is a bogus app within this category, the Federal Trade Commission (FTC) has shown that they are willing to exercise their power to have it pulled off the market using "false advertising" as the rationale. [Mashable includes a health app in a list of app developers that the FTC prosecuted in 2011]. But this is also a very small percentage.

In response to this, we've come up with a Blue Ribbon Panel that is made up of a leading physician, a leading nurse, a leading medical technologist, and a leading patient advocate to develop a protocol for the certification of apps as being medically sound within their category. They are currently drafting the process and protocols that will be followed to do this certification. Once they are done, we will put in place a mechanism to allow developers to upload their apps for certification and to receive feedback on what they can do to improve their apps to meet the criteria. Once an app is certified, they will be granted a license to use a "trust mark" for the promotion of their apps. This mark will signal to both clinicians as well as patients that this app is safe and sound.

This is a big job but it is one that needs to be done and we are in hopes of having something out in about 4 months. 

 

How secure is the digital medical information collected via health apps? What security measures protect this digital medical information?

Private health information that is shared with your physician or any other healthcare provider is covered under the privacy aspects of the Healthcare Insurance Portability and Accountability Act (HIPAA). There are a number of technical requirements that an app developer must ensure if they fall within the HIPAA domain. As part of our certification process, we will examine how the app functions, and if it falls within the HIPAA privacy requirements we will assess if the app complies with those technical needs. If an app developer falls under HIPPA privacy but fails to meet the requirement, we will notify them and explain it to them.

Can you explain the process that Happtique will use to rate different health apps?

We are not going to rate apps but rather certify them. In our app stores that we make available to hospitals, clinicians, and patients, we will allow them to rate and comment on apps, but the certification process is independent of that. Thus, when we discover an app (either because it is sent to us or we find it in one of the public app stores) we will first classify it by placing it in the right categories to allow our end users to find it. They will then rate the apps based upon their experience and we will segment those rating based upon what type of audience that they make up. Finally, for those developers who want to be certified, we will make that available for a fee and they will need to provide us with access to their app.

We are doing curation right now and it is available to clinicians who sign up at our website at www.happtique.com. The ratings engine is also turned on and anyone with our catalog app running on their devices can start rating apps.

When your doctor prescribes an app: A Q&A with Happtique (Part I)

If you have a smartphone or a tablet computer, your AngryBirds app might have some new company soon: apps prescribed by your doctor to help you manage your health. Last month, I heard Paul Nerger, the Senior Technology Advisor for the mobile application management company Happtique, talk about the brave new world of health apps at a mobile health panel (hosted in part by the German American Business Association). Intrigued, I asked him to answer some questions about health apps for this blog. 

This is the first post of a two-part Q&A about health apps and how they will impact health care. This post explains who uses and develops health apps. Part II, to be posted next week, explores how health apps are regulated, certified, and rated. 

 

Who uses health apps for smartphones the most: health care providers or consumers/patients? Which group do you think will be driving demand for health apps in the future?

Both.  

Clinicians use professional apps that make their jobs easier. That could be anything from keeping up-to-date on the latest medical journals, using a medical calculator, connecting with a colleague on advice, using the EHR system in the hospital, to looking up the bus schedule to figure out how to get from one facility to another.  

Patients use apps to make their lives better and more healthy. It could be a diet app, or asking questions about their health, or for those on the leading edge, tracking their own medical records.

The really interesting aspect is what happens in the future. In the near future, these two communities will start to interact with each other in ways that we've not seen before. Clinicians will start to "prescribe" apps to their patients and patients will like this because patients (i.e., all of us) trust their physicians and other healthcare professionals who look after us. With over 30,000+ apps available to help us manage some aspect of our health and well being, we will want help in figuring out what is good and what is bad, and our physicians and other clinicians (e.g., pharmacists, nurses, dietitians) will be in the perfect spot to help us.

But the clinicians need help also: they need to be able to discover an app that helps with our particular clinical condition, they need to be confident that the community within their particular professional association is confident that an app is clinically sound, and they need an easy mechanism to prescribe this to any given patient.

These are the problems and challenges that we've given a lot of thought to and are building at Happtique. 

 

What are the most popular health apps currently available?

There are two major categories of apps out there: medical and healthcare. The medical category is really for professionals. Apps such as Epocrates, Skyscape, 5MinuteConsult, Calculate by QXMD, MedPage Today and others are very popular with this community since they are needed by all clinicians. That does not mean that there are not some fantastic apps that are designed to solve a particular problem. For example, you might be a pediatric oncologist and you want an app to run on your iPad to help with informed consent--there is probably an app for that. Thus, the most popular medical apps might be the ones that fit a particular clinician's needs best.

And the same is true for the health apps. The most popular app for an MS patient will be very different than the most popular app for a type 2 diabetes patient.  

In other words, the quest for the "killer app" is the wrong way to look at it. Each of us, be we clinician or patient, will have our own basket of apps that makes our mobile phone or tablet right for us. Thus it is a world of choice and choosing the collection of apps that fit our need.

Again, this is why we at Happtique curate all of the medical and healthcare apps under the sun. It is important that we enable you and your physician to choose the right basket of apps to fit your needs.

 

Who develops health apps, and what is their motivation to develop an app?

I've seen apps built by physicians who want to make it easier for the patients that they treat to receive treatment. I've seen apps built by students who encounter a fellow student or teacher that they want to help make their life easier with a particular app. I've seen medical professionals working with engineers who see particular problems in the hospital that they want to solve and thus they build an app. I've seen leading clinicians who simply want to improve the outcomes of their class of patients. I've seen professional developers who see a market to serve and want to build a business.

In medical and healthcare, there are lots of developers coming from different backgrounds who are developing apps, but the common thread is a heartfelt desire to improve the quality of care, the quality of life, while lowering the cost of healthcare for patients. And this is why mHealth [mobile health] is different than other segments. mHealth deals with the stuff which our lives are made of and thus it is a noble cause regardless of the place that you come from.

Improving CT Scans, Treating MS: Notes from an IR Conference

I am slightly obsessed with the topic of radiation exposure, since I have covered radiation overdoses from CT scans on this blog and written about radiation issues in post-earthquake Japan and treating radiation injuries for Medscape. So I was interested to learn about efforts to decrease radiation exposure in patients when I stopped by the Society of Interventional Radiology's annual meeting in San Francisco last week.

Interventional radiologists (IRs) perform many minimally-invasive procedures, such as placing stents in arteries to increase blood flow or delivering targeted chemotherapy to a tumor. These procedures can often replace more invasive and riskier open surgeries. But the flip side of this medical progress is that some of the imaging technologies used to guide these procedures, specifically CT scans and X-rays, expose patients to ionizing radiation, the type of radiation that can harm DNA. 

A poster at the session explained that CT scans are a key source of radiation exposure in the U.S. This exposure can be decreased by adjusting the CT scanner and basing the dose on the patient's BMI, explained author J. Collins et al. ("A Practical Guide to CT Dosimetry for the Interventional Radiologist").

Another intriguing development covered at the conference: the use of angioplasty (widening a narrowed blood vessel) to treat multiple sclerosis. Angioplasty can clear blockages in veins that might contribute to MS symptoms. Some patients who were studied reported that their symptoms improved after the procedure. The course of MS can be so fickle, though, that it's hard to tell whether symptoms improved or the disease simply relapsed for a while, reporter Laird Harrison explained in a WebMD article on the topic ("Treating Clogged Veins Improves MS, Study Says"). The press release about the procedure from the Society of Interventional Radiology is available online.

Lessons from female crash test dummies

The Washington Post had an interesting article yesterday about the use of female crash test dummies to test car safety in 2011 cars. These dummies, which are lighter and smaller than the male dummies used in the past, provide very different safety data than the male dummies. Some cars tested with the female dummies now have lower safety ratings than they had with male dummies ("Female dummy makes her mark on male-dominated crash tests").

Women drive less than men, but because they tend to be smaller than men they are more vulnerable to injury in car crashes, writer Katherine Shaver points out. They are also more likely to be in the passenger seat than in the driver's seat when traveling with others, which increases their risk for injury and death.

Despite these gender differences, the National Highway Traffic Safety Administration has used only male dummies to create crash test ratings for cars in the past. The story about the use of new female dummies in the 2011 ratings is worth reading to better understand the true risks of driving for women, which the auto industry can address with improved safety features.

How mobile phones improve public health

Smartphones and cell phones are increasingly playing a role in public health. Combine a smartphone with crowdsourcing and infectious diseases, for example, and you end up with a novel concept called participatory epidemiology. The Outbreaks Near Me app for iPhone and Android, for example, released during the swine flu epidemic in 2009, collects data from users and from the media to track the flu and other diseases in every part of the country. Install the app and you can see what disease might be tearing through your city right now (in my neck of the woods, it's the highly contagious Norovirus).

Mobile phones are also used to manage the response after disasters and disease outbreaks. In an interesting article about participatory epidemiology written by the creator of Outbreaks Near Me, the authors cite applications such as Ushahidi, used to manage the response after the Haitian earthquake in 2010, and GeoChat, used to track diseases in Southeast Asia (you can read about the pros and cons of participatory epidemiology in the article "Participatory Epidemiology: Use of Mobile Phones for Community-Based Health Reporting").

For health care providers in resource-poor countries, tracking data on a smartphone is actually easier than tracking it on paper, according to a study released by the CDC this week ("Smartphones more accurate, faster, cheaper for disease surveillance").  In the study, providers collected data for questionnaires about influenza in Kenya using either smartphones or paper forms. The smartphone data was more thorough and (since it was digital) quicker to access in a database than data recorded on paper. What's more, the 2-year cost of implementing smartphones to fill out these questionnaires was also lower than the cost of collecting the data on paper.

More widespread collection of health care data can serve the public good. Perhaps that's how health care data should be seen: as a public asset that we can all contribute to and that we all benefit from. As more health care data is digitized for easier access by public health officials and other entities, however, it becomes increasingly important to protect the privacy of each contributor.