Patients will be able to have consultations with nurses on their iPhones through an NHS app that offers a digital way into the health service.
Video calling has been added to the 111 urgent care line in Staffordshire in a pilot scheme that could lead to the app becoming a standard way to get medical advice.
Health bosses hope that smartphone access to the NHS will encourage young people not to go to A&E for minor problems, relieving pressure on the overstretched emergency system. Doctors, however, fear that people will be tempted to use the app for instant consultations instead of waiting for GP appointments, warning that it must not become a “convenience service”.
The 111 helpline is designed for urgent but non-life-threatening problems and NHS bosses say that it allows millions of people to get help without going to A&E or get an out-of-hours GP appointment. Yet the service has been criticised by doctors who say it is sending out too many ambulances and telling people with trivial ailments to go to A&E because it is staffed by call handlers with no medical qualifications.
For the next two months, patients in Staffordshire will be able to use the iPhone app at evenings and weekends to speak to 111 call handlers. Nurses and paramedics will also be available.
A spokeswoman for NHS England said: “The aim of the app is to provide current NHS 111 service users with a choice of channel and to improve accessibility for future, technologically focused, generations.”
The pilot scheme will assess whether patients feel more comfortable face to face and whether being able to see callers cuts down on referrals to A&E and GP services. If it proves successful, the app will be made available nationwide.
Dr Charlotte Jones, 111 spokeswoman for the British Medical Association, said that a video link would be helpful for some conditions. “Things like rashes aren’t easier to describe over the telephone so seeing them is helpful. You might have a mum in the middle of the night worried about little Johnny and we’re able to reassure them it’s not meningitis,” she said.
Dr Jones expressed scepticism, however, that the phone line staff would make better decisions. “They are working to an algorithm so just because they can see the patient doesn’t affect what the algorithm is telling them,” she said.
She added that patients were less able to manage problems at home and increasingly turned to the NHS. “It’s not unheard of for people ringing up to say ‘I need a plaster on my finger, can you help?’ You have really trivial things coming through. We’ve turned more into a convenience society. Until we have enough resources to deliver convenience [the service] has to be based on what patients need, not what they want.
The Royal College of Emergency Medicine, pointed out that 111 sends more people to A&E at the weekend when other services were not available. “We don’t know how useful this would be. We think it unlikely that it will substantially change the numbers of patients attending A&E departments,” a spokesman said.
Diagnose Depression
CLINICAL depression is, simply put, a dreadful disease. Diagnosing it is anything but simple, however. Its symptoms vary, can shift with the ups and downs of everyday life, and sometimes overlap with those of other diseases. For these reasons, it is common for depression to go unidentified for months, or even to be missed altogether.
Stefan Scherer of the University of Southern California and Louis-Philippe Morency of Carnegie Mellon University, in Pittsburgh, hope to change this. They are trying to develop a reliable way of diagnosing depression by using a computer to record and analyse aspects of a putative sufferer’s behaviour. They are, they think, 85% of the way there.
Their latest research, just published in IEEE Transactions on Affective Computing, is an analysis of depressed people’s speech. It follows up on analyses of facial expressions and eye movements carried out by tracking cameras while the subject of a diagnosis is having a conversation. These used things like the length (or, rather, shortness) of people’s smiles and the frequency with which they looked at the ground in order to develop an algorithm that was 75% effective in diagnosing depression.
The extra 10% of reliability has come from quantifying what was previously a qualitative observation, which is that depressed people tend to run their vowels together when they speak. Dr Scherer and Dr Morency programmed their software to record patterns of vowel-spacing (known as vowel-space ratios) and then tested the system on more than 250 people, some of whom had been diagnosed independently as depressed and some of whom had not.
The software found that depressed participants’ vowel-space ratio in normal speech was 0.49 (compared with 1.0 for a reference population reading a standard word list). That of healthy participants averaged 0.55. A small difference, certainly—and not enough by itself to be a reliable diagnostic tool. But combined with the researchers’ previous work, this was a palpable advance.
Dr Scherer and Dr Morency are not yet proposing that their program replace psychiatrists. But doctors are busy people, and the new diagnostic system can spend time observing a patient that a doctor cannot. Working together, human and machine should bring faster, more reliable diagnosis of depression.
I WAKE up feeling lousy. The app on my phone tells me I had a fitful night’s sleep, which might have something to do with it. But I feel worse than just tired, so I go to the bathroom and pee on a sensor strip. Most metabolites are fine but there’s an excess of nitrites, which could indicate a urinary tract infection.
Back in my bedroom I run more tests. My blood results tell me my vitamin D levels could be higher – but I live in dreary London, so I knew that already. My heart rate and blood oxygen are fine, though my inflammation levels are higher than normal. Then I swab my nose and the machine by my bedside takes just a few minutes to tell me what’s really wrong: I’ve got the flu. A quick look at the flu map on my phone tells me that 8 per cent of the neighbourhood has succumbed. I’m just another red dot.
The way illness is diagnosed is changing, and we are all invited to take part. Each of the technologies described above is on the market already, or will be soon – and there are a lot more where those came from.
Some will feel familiar to people who already monitor their health with smartphone apps or wearable devices. But there’s a difference: instead of merely tracking lifestyle indicators such as sleep quality, diet and physical activity, they will also deliver medical diagnoses and advice. Welcome to the age of DIY diagnostics.
Apps and wearables are already moving in this direction. You can buy an elecrocardiogram to attach to your smartphone, for example, and top of the range fitness trackers can now log your pulse and respiration rate; the next generation will also track blood pressure, glucose levels, hydration and blood oxygen.
Next will come a range of gadgets that bring professional-level diagnostic equipment into the home. In December, San Diego company Cue will ship the first generation of its bedside-table device, a little white box that can diagnose flu and measure four vital signs: vitamin D levels, inflammation, female fertility and testosterone.
Meanwhile, the 10 finalists of the $10 million Tricorder X Prize started testing their Star Trek-style “pocket doctors” on people last month. The prize will be awarded to the first hand-held device that enables somebody without medical training to diagnose 15 medical conditions and monitor five vital signs (see “Tricorder tests“). The winner will be announced in January and it won’t be long before the devices are on sale to the public.
Those behind this emerging industry say the goal is a healthier, more engaged population who visit their doctor less often – and when they do, arrive with a diagnosis and data to back it up. “This will bring about a profound change in the way healthcare is delivered,” says Ali Parsa, chief executive of digital healthcare company Babylon.
But others fear we are asking for trouble. How reliable are the tests? What if, rather than keeping people away from the doctor’s office, they cause a stampede towards it? And who owns the data that this diagnostic boom is going to produce?
The first home diagnostic was a pregnancy test launched in the US in 1978. Today you can buy dozens of home tests online or from pharmacies for anything from infectious diseases such as TB to the onset of menopause.
However, getting reliable information about how good the tests are isn’t easy. A few have been approved by health authorities, but many more have not. In 2011, UK magazine Which? asked two doctors and a panel of 146 users to evaluate six of the most popular ones. They concluded that people would be better off saving their money and going straight to their doctor, who would run their own tests anyway.
The newcomers want to change that. “Current consumer diagnostics aren’t very satisfying,” says Eugene Chan, head scientist at the DNA Medicine Institute (DMI), one of the companies shortlisted for the Tricorder X Prize. “They need to be confirmed by a more sophisticated method” – which is exactly what DMI and its competitors are aiming to provide.
Then there’s the fact that existing tests generally diagnose just one specific condition. That’s fine if you already have an inkling what’s wrong, but what if you don’t? “The tricorder devices are designed for people who may not know what is wrong with them,” says Grant Campany, senior director of the Tricorder prize. In that sense, the devices work more like a doctor: they ask questions about symptoms and then run tests to reach a plausible diagnosis.
Exceptional opportunity
All this is being made possible by advances in artificial intelligence, wireless sensing, diagnostic imaging and lab-on-a-chip technology, as well as the ability to shrink it all down into a compact device. Couple that with the increasing sophistication of smartphones and cloud computing, which allow medical data to be stored and shared, and you have “an exceptional technical ecosystem for healthcare”, says Campany.
That’s the marketing pitch anyway. But there’s many a slip between pee cup and stick.
An obvious concern is accuracy. If home diagnostics produce ambiguous, hard-to-interpret results or high rates of false positives, the upshot is likely to be even greater demand for medical appointments. Similarly, a high rate of false negatives might misleadingly reassure people and cause them to delay seeing a doctor when they really need to. We have seen the problems that both types of error can cause with population-wide screening programmes, which have largely been withdrawn or scaled back because, overall, they do more harm than good.
A related issue is how people respond to the results. Being diagnosed with a serious disease can be traumatic; without professional help to put the result in context, it can be even worse.
Ideally, DIY diagnostics should be tested in clinical trials, says Annette Plüddemann, director of the Diagnostic Horizon Scan Programme at the University of Oxford – both to assess their accuracy and to ensure that they help people make sensible decisions. Yet few such trials have been done for the tests on the market, she says. Exceptions include a HIV test recently approved in the UK and US, and glucose monitoring and clotting tests.
The trouble is, manufacturers don’t have to carry out clinical trials to gain approval to sell their products. “We need a better regulatory process,” says Chris Price, an expert in diagnostics at the University of Oxford. Much of the current UK regulation assesses how technically good a test is, but not whether it helps improve the user’s health, he says.
Accuracy is already an issue for smartphone apps. For example, an independent test of 46 apps designed to calculate how much insulin people with diabetes should take based on their blood sugar and the carbohydrate content of their next meal discovered that two-thirds carried a risk of inappropriate dosing.
The makers of next-generation diagnostics are confident that they can do better. The US regulatory process for such devices is still a work in progress, but Campany says he expects the Food and Drug Administration to demand clinical trials to validate the safety and accuracy of tricorders before they go on sale.
Chan agrees. “We’re aiming to have the same gold standard as laboratory diagnostic tests,” he says. Ayub Khattak, CEO of Cue, is similarly confident: “We do a lot of testing relative to standard lab tests and we’re very good,” he says.
Assuming that diagnoses are good enough, the next task will be to ensure they lead to an appropriate medical follow-up. “It’s naive to think that the technology by itself is enough – you need the support package,” says Jeremy Wyatt, head of e-health research at the University of Leeds, UK. That might just mean a prescription or referral to a specialist. But it could be more involved, such as counselling or 24-hour support.
For that to happen, DIY diagnostics will have to be accepted by doctors, though this doesn’t look like a major hurdle. Doctors in the UK already encourage people to monitor their own blood pressure and other indicators, and the National Institute for Health and Care Excellence has endorsed self-monitoring for people with diabetes and those on blood thinning drugs. Widening the net to self-diagnosis isn’t too much of a step into the unknown. “If the tests are of suitable analytical quality and they have been shown to be clinically useful, I don’t see why doctors wouldn’t support them,” says Price.
In a survey of US doctors, researchers at PwC’s Health Research Institute found that over half said they would be comfortable using vital-signs data from an app to prescribe medication, and 47 per cent said they were happy to prescribe drugs based on a self-administered test.
Good-quality follow up should also help prevent an epidemic of hypochondria similar to the one that struck when people first started Googling their symptoms. In 2008, Eric Horvitz of Microsoft Research in Redmond, Washington, co-authored the first systematic study of this issue. He concluded that medical web searches frequently lead people to think the worst – a phenomenon called “cyberchondria”.
“Web searches often lead people to think the worst – a phenomenon called cyberchondria”
“Most folks are just fine,” says Horvitz. “But with the introduction of these new devices, promising as they are, we will have to balance the value against the cost in dollars and anxiety.”
Consumers are likely to have another anxiety too: ownership and security of their health data. In a recent survey, also carried out by PwC, 76 per cent of people said they were concerned about the security of their medical records and 68 per cent about that of health data stored in smartphone apps.
Again, the companies say they have this covered. For most diagnostics in the pipeline, data will be encrypted, password-protected and stored on the company’s servers. “Users would have their own account for this information, like the way you have your own email address,” says Chan. Details are anonymised and people can decide whether to opt in to share them, for example, on Cue’s Flu Map. The data is thus as secure as anything else stored in the cloud.
There is clearly still much that we don’t know about what happens when DIY diagnostics meet the real world. But some are already looking forward to the next step.
“We will shortly see the advance of artificial intelligence in healthcare,” says Parsa. “Machines will be learning everything there is to learn about health and medicine.” IBM’s supercomputer Watson is already helping doctors to diagnose cancer, and will soon be genned up on other conditions. The Tricorder teams are currently using their own diagnostic algorithms, says Campany, but he can envisage Watson being recruited at some point to create an even more powerful device.
Another promising direction is to utilise diagnostic information that is out there but not currently used, says Tim Riedel of the University of Texas at Austin. There’s already an app that diagnoses a type of eye cancer from selfies. What about the colour of your tongue, or changes in the way you type on a keyboard? “Tricorders are cool, but what would be cooler is if we can harness devices people already have,” says Paul Wicks, head of innovation at patient-support website PatientsLikeMe. “Call it capturing the data exhaust. It seems a bit less sexy than a new machine that goes ‘ping’. But two years ago we were talking about Google Glass and all the applications for that. Look what happened”.
One thing seems clear: whether you are ready for it or not, the way we diagnose diseases is undergoing some serious DIY disruption. And we are just at the tip of the iceberg, says Riedel. “I keep telling my students: ‘I got my first cellphone when I graduated college. You were handed one in your crib’. They and the generation after them will make diagnosis happen in mind-blowing ways we can’t even think of right now.”
New Doctor Services
House calls by doctors used to be commonplace in the United States, as in Britain. Now, a new generation of American start-ups is reviving the practice, bringing the Uber on-demand model to the healthcare sector.
GPs are now providing a real-life and high-tech version of TV’s Doc Martin
These streamlined services, which reduce primary care costs by cutting out waiting rooms and receptionists and delivering a doctor to your door, are attracting growing interest from venture capitalists.
Available through smartphone apps or the web, these new services also hope to improve the nation’s health by encouraging people to seek medical attention when they need it, while at the same time reducing the pressure on accident and emergency departments full of people who do not need to be there.
The trend in on-demand healthcare and concierge care has been helped by the development of a new generation of transportable medical gadgets such as mobile imaging machines and heart monitors.
In New York city and San Francisco a company called Pager will send a doctor to your home within two hours, charging $50 for the first visit and $200 for subsequent visits. It recently secured $14 million in a Series A funding round, bringing its total venture funding to $25 million.
Gaspard de Dreuzy, a cofounder of Pager (another, Oscar Salazar, is also a cofounder of Uber), says that the company started with emergency care doctors who worked for it several days a week. Now many spend most of their time working for the service. “It’s a better way of providing care. It’s very personal,” he says. A lot of his customers are working mothers of 35 to 45 who enjoy the convenience of a home visit and find it affordable. Mr de Dreuzy adds that the service is not an alternative to going to an accident and emergency department and that his doctors will advise patients to call 911 or go straight to hospital if necessary.
Pager is competing with a raft of other services. Heal, which began in Los Angeles and San Francisco, has raised $5 million in a seed round from investors including Pritzker Capital.
San Francisco-based Doctor on Demand, whose backers include Google and Andreessen Horowitz, offers video consultations with doctors for $40 or psychoanalysis consultations for $50 to $95. Patients rate their doctor just as they would rate an Uber driver or Airbnb host. Other providers include Atlantabased MedZed, CurbsideCare in Philadelphia and Go2Nurse in Chicago. Medicast, based in Miami, has raised nearly $2 million in seed funding for its customisable platforms that help to provide on-demand care.
In Britain, such services are being pioneered by Dr Now, headed by Savvas Neophytou, a former pharmaceuticals analyst, offering online GP consultations using Skype.
RetraceHealth, in Minneapolis, offers video consultations with a nurse practitioner for $50 and home visits for $150. Thompson Aderinkomi founded the company in 2013 after a medical emergency involving his one-year-old son required a series of doctor and clinic visits that cost the family $600, after insurance, and ate up many hours of waiting and travel time.
Mr Aderinkomi, a health economist, is very focused on reducing medical costs. He says: “About 50 per cent of a clinic’s fees go on overheads. Because of our use of technology and because we don’t have a clinic, our overheads are closer to 10 per cent.” He has raised $500,000 so far and is in the middle of a second funding round backed by venture capitalists.
The main obstacle to expansion has been persuading health insurers to cover such services. One objection is that on-demand healthcare encourages people to seek unnecessary medical attention because it’s so easy to use, a point that Mr Aderinkomi emphatically denies. “People on a membership plan do not use the service any more than people who pay per visit. Primary healthcare is not like pizza — nobody really wants to use it,” he says.
The insurers are not the only ones with reservations. Many in the medical profession believe that on-demand health services lead to a fragmentation of care and poor follow-up services.
There’s no doubt, however, that these services are meeting some very serious needs. Although some claim that America has the best healthcare in the world, access to primary care remains a big obstacle and the average waiting time to see a doctor is 20 days. There is also a worrying lack of transparency surrounding costs.
It seems inevitable that the health insurers will eventually come round. America has been here before. When a company called Minute-Clinic launched America’s first retail walk-in clinic in 2000, many doctors were aghast, warning that they were not the best place to treat vulnerable patients such as children.
Most major insurers started covering the clinics within a couple of years, and by 2006 the giant drug store chain CVS had bought the business just as Wal-Mart Stores and CVS’s rival Walgreens moved into the field.
America’s on-demand healthcare service is still in its infancy, but Mr de Dreuzy thinks there is plenty of room for expansion —and the amount of venture cash it is attracting suggests that others do, too. “The big question is ‘how can you scale up?’. We have decided to partner up with larger health systems city by city so that we can tap into their doctors,” he says.
This could also mean partnering with, rather than competing with, existing healthcare systems, not just in the US but around the world, including Britain.
Why Are You Coughing?
ResApp
UNIVERSITY OF QUEENSLAND, AUSTRALIA
WHAT IT DOES: Determines the cause of a cough
HOW IT WORKS: Because respiratory diseases, such as pneumonia, alter the structure of the respiratory tract, each one creates a unique sound signature in a patient's cough. Based on four to five coughs, signal-processing algorithms in this app can detect those patterns, identifying both the type and severity of an ailment.
STATUS: A proof-of-concept trial of 91 patients in 2013 diagnosed pneumonia and asthma with 90 percent accuracy. A second, larger trial is under way; the additional data should allow refinement of the app for bronchitis, bronchiolitis and upper respiratory tract conditions. A version could be ready for release to doctors next year.
New Age Medical Care: Surgeons treating four-month-old
Teegan Lexcen (born with only one lung and a critically deformed
heart) had given up on her, but doctors at Nicklaus Children's
Hospital in Miami jury-rigged a surgical tool that saved the infant's
life. In a delicate seven-hour procedure, using an iPhone app and
$20 Google Cardboard box virtual-reality viewers, doctors guided
themselves through Teegan's chest based on two-dimensional body
scans that the app had converted to 3-D. (Old-style 3-D images,
they said, were too grainy for precision surgery.)