One of the more striking images to me, out of the online spew in the last few months, was from the inauguration. It was a wide view of an inaugural ball. There was the president waltzing with the first lady, and a crowd of several hundred watching them. What was striking about that image was that the several hundred people held several hundred small glowing rectangles in their hands. Practically every member of the crowd was carrying a smartphone and was photographing or videotaping the moment.
The scene was commonplace in its moment, remarkable only in the perspective of history — but such a short history. We could not have imagined so many people carrying smartphones at Obama's first inaugural only four years ago. Four years before that, we could not have imagined any. The iPhone had not been invented.
There had been attempts at smartphones before the iPhone, and devices like tablets before the iPad. But the rampant success of iOS devices did far more than establish two profitable niches. It changed our relationship with the world.
The Apps Make the iPhone
Apple and Steve Jobs certainly have their fans. At the time, much was made over the iPhone's clever design — and much has been made since over whether its competitors have outdone its clever design. But the most significant invention embedded in the iPhone was not the device. It was Job's insistence that:
- the device would be home to multiple features encapsulated in small programs called "apps";
- these programs would be relatively inexpensive and radically easy to use;
- they could be made by any developer who wanted to make one;
- the device would be able to sense, communicate and compute to serve the apps.
It was this series of tightly connected design decisions that was revolutionary. They set the shape of the mobile universe. They are what made the iPhone and its competitors and the iPad and its competitors so wildly successful. We are only at the edge of understanding how deeply that success changes the world. It means that everybody is walking around with extraordinarily powerful devices for sensing, recording, computing and communicating in their pockets — devices that, with the addition of the right apps and other plug-in devices, can be turned into more different machines than we can even imagine.
My iPhone has a guitar amplifier on it. It has the descriptions, calls, pictures and video of more than 1,000 birds. It has an app that captures every receipt and uploads it instantly into the cloud, and another by which I can deposit checks into the bank. Turn on one app, point the phone at a sign in Mexico, and there is the sign on the phone, same sign, same typography, except it's in English. The possibilities are literally endless.
Apps in the Clinic
There are, of course, thousands of medical apps for both clinicians and consumers. But here again, I don't think we've begun to imagine what the hyperconnected, app-enabled future of medicine looks like.
The great majority of the apps now available communicate information, everything from consumer health information and reminder nags to electronic health records and image displays for clinicians. These are extremely useful and change the workflow of the clinician and the relationship of the clinician to the patient. But the world of medicine begins to look very different with apps (and devices connected to the smartphone) that don't just communicate information, but actually do medicine — diagnostics, telemetry and therapy — on the smartphone or tablet.
There are cheap dongles that can do sonograms good enough for office use; sensors and apps that can do blood tests, sweat tests and other chemical diagnostics. One type of pill has been developed that reports when the patient has swallowed it. When the pill encounters stomach acids, it sends out a tiny electronic pulse. The pulse is picked up by a small adhesive patch the patient wears on his or her abdomen. The patch, in turn, detects when the patient's smartphone is on and close by, and sends out a Bluetooth signal. An app on the phone picks up the Bluetooth signal and sends an instant message to the clinician who is tracking the use of the drug.
More of these apps and dongles for practicing medicine on the smartphone or tablet are arriving every day. What difference will they make? Is this just another fad? Or will they fundamentally change the lives and workflow of doctors, their relationships to patients and the shape of your institutions?
Here's something that'll help you start thinking about this: Dig up a recent video of Eric Topol, M.D., on NBC's "Rock Center." He demonstrates a number of apps and gadgets. He mentions that already, as a cardiologist, he prescribes more apps than drugs. He demonstrates an iPhone device that derives an EKG from the pulse in your fingertips, as well as a wrist device the size of an iPhone that delivers all of the telemetry needed from a patient in an ICU. He mentions a pill and app combination in development that is expected to be able to predict your heart attack or stroke a week in advance.
There were several things to notice in this video once we get past the "Oh, wow!" reaction. One is the relationship between the patient and the clinician.
It is a common worry that technology increasingly will come between the doctor and patient. This technology, as demonstrated by Dr. Topol, clearly does the opposite: It allows the doctor to work much more closely with the patient during the exam. There is no need to send the patient elsewhere for an EKG or sonogram, then await the report and have the patient come in again to go over the results. The scan is just part of the conversation with the doctor. With such devices, the patient even could be sending the sonogram from home, while having a conversation with the doctor over the phone.
When we try to imagine what kind of impact apps and small devices will have on the future of medicine, this is a major thing to ask: Does it help the doctor work more easily and productively with the patient? Does it ease the doctor's workflow?
Second thing to notice: At several points Dr. Topol mentions the price of the app or the device that is plugged into the phone. The prices he mentions are always low — in fact, absurdly low compared with the prices of the things they replace. So when we imagine doctors trying out these apps and devices and seeing how they fit into their practice, the bar is low and experimentation will be the order of the day.
Unlike a new clinical information system, which can take years and millions to billions of dollars to choose and implement before the doctors get to try them out in their actual practices, doctors will try out and discard apps and devices the way we are already used to trying out apps on our smartphones — easily and quickly, trying a number of them before we settle on one that really works for us.
Third thing to notice (and in some ways the most important): In discussing the EKG device, Dr. Topol mentions that we do some 20 million EKGs per year in the United States, and in his estimation some 80 percent of those could be done with a smartphone device in the doctors' office.
Hospitals and health systems are not just in the medical business, they are in the laboratory business and the imaging business as well. Just for argument's sake, let's imagine that Dr. Topol is correct. Imagine that small devices and apps used in the examining room by the doctor directly with the patient can substitute for the great majority of the lab work and imaging now done by your hospital, your health system and its affiliates. When we talk about health care shrinking, becoming more lean and efficient, cutting its workforce without cutting services, this is one of the ways we can imagine it happening.
As in other aspects of health care, the speed with which this change will take place depends not only on the ease of use of the apps and devices, and whether they help with the doctor's workflow. It also depends on the underlying economics. In an old-fashioned, strictly fee-for-service system, doctors and health care systems profit from their inefficiencies. Every unnecessary test, scan and admission adds to the bottom line.
As more systems and individual clinicians come to be, in one way or another, at risk for outcomes, they increasingly will be in a position in which inefficiency is a cost, rather than a profit center. In this atmosphere, every avoided test helps the bottom line. Perhaps more importantly, in this atmosphere, a close, constant, informed and productive relationship with the patient is more profitable than another test for which you can charge.
This changed relationship and greater efficiency will be particularly attractive to clinicians as we edge into the Accountable Care Act era, and get tens of millions of new customers. In the past, the economic question for both doctors and hospitals was: How can we drum up more and larger reimbursements? There was an economic incentive to the extra test, as well as the return office visit.
But we don't have enough doctors for the new era. Increasingly, even in a fee-for-service universe the economic question, particularly for physicians, will be, "How can I more effectively and efficiently serve many more patients without driving myself crazy?" If that is the question, then mobile devices and apps that can smooth the workflow, speed patient contact, and prevent the need for extra tests or extra office visits become a big part of the answer.
What Did We Do before Apps?
We are approaching a tipping point, after which the use of such apps and devices in the medical context will become so commonplace that we will have difficulty remembering how we did without them. At first they will just be used to supplement our usual procedures. But very rapidly they will supplant many of those old procedures and tests. When that happens, we can expect the demand for lab results and various types of imaging to drop off drastically, while our IT departments will not only expand, they will take on the larger and more varied mission of supporting, coordinating, providing backup and realistic security for an ever-changing plethora of mobile devices, dongles and apps.
It's a different world, and it's in everyone's pocket.
Joe Flower is a health care futurist and CEO of The Change Project Inc. and its health care education arm, Imagine What If. He is also a regular contributor to H&HN Daily and a member of Speakers Express.