THE HONEYBEE CHRONICLES: PART ONE
An interview with Steven Lester, Consultant Cardiologist, Mayo Clinic, Arizona
By Claire Topal, Senior Research Consultant, Center for Sustainable Health
CSH: What motivates you to spend so much time and energy on connecting the practice of medicine to biosensor technology?
SL: We are often extraordinarily inefficient in the way we manage patients. According to the first Chinese medical text, “Superior doctors prevent the disease. Mediocre doctors treat the disease before it is evident. Inferior doctors treat the full-blown disease.” The modern hospital and much of healthcare as we presently know it are products of the Industrial Age. Hospitals have become healing factories and physicians healing mechanics. The patient gets sick, is fixed, and then sent on their way until they break down again. This system may promote good medical care but it creates inferior and mediocre healthcare.
Given the unsustainable increased costs of healthcare, we must do better. The world of healthcare has a huge opportunity to further embrace and leverage technology to help us shift closer to the “superior doctor” mindset. In my opinion, biosensors will be a key catalyst in support of this transformation for healthcare organizations—from managing the sick to focusing on health and the prevention of disease. If we can embrace the changes that are afforded by recent advances in technology, we can support physicians to become “superior doctors”.
CSH: Is our system structured to effectively support prevention and that superior doctor mindset?
SL: Unfortunately, there is not a robust funding platform for today’s healthcare organizations or healthcare providers to promote health and wellness. Most healthcare organizations and providers are used to being reimbursed for the services they provide—more services mean more income. There’s not a lot of incentive to keep people well. But the evolution of healthcare payment reform means that eventually hospitals, and healthcare organizations and providers, will likely rely on global budgets with quality incentives to provide healthcare to a given population. Funding will reflect the health of the population along with positive outcomes, instead of the number of services provided. In this funding model, the most advantageous avenue is the least cost option – namely keeping people healthy and away from the high costs associated with hospitalization. In other words, reimbursement will drive the healthcare industry to do what it is supposed to do.
Basically, this incentivizes prevention over treatment, because treatment (and sickness) becomes more expensive for the physician and the healthcare organization. It’s definitely not an easy shift, but it’s coming whether we like it or not. I happen to think it’s necessary.
CSH: Where does communication and biosensor technology fit into the system of tomorrow?
SL: What drives me is this Internet-driven future where there will be a huge growth of machine-to-machine connections, with greater and greater capacity and speed to support all these new connections.
The first wave of a more connected world in healthcare will be these biosensors to track health, wellness, and fitness. The evolution of these technologies bridges the physical world that we live in to the digital world. Biosensors in general monitor various physiological signals from our bodies, and importantly, they enable me, as a physician, to be able to detect when a person is either developing a disease, having it decline, or developing any change in clinical status. The fact that these sensors are wearable and don’t rely on hospital infrastructure means that patients don’t need to be in the hospital or even in my office for me to track them and receive these signals.
CSH: In addition to supporting disease prevention and early detection, are there other benefits to biosensors in a clinical setting?
SL: Yes – cost reduction. What has frustrated me as a clinician is that so many patients come to the hospital because they are sick, and then are admitted because they are sick. But with relatively simple tools and communication structures we probably could have identified a change in their health status weeks prior to their presenting. We could have intervened early and removed or reduced the need for the hospital. But, of course, we have no regular communication with the patients—no way to understand if or when they start to get sick before they are clinically unwell. As a result, by the time they come to me, the horse is too far out of the barn. This situation represents hundreds of thousands of hospital days in this country. Most frustrating is that these hospital days are often unnecessary, chewing up healthcare dollars and resources.
I think biosensors can help us create a patient-focused care model and the delivery of care closer to home, enabling disease prevention as well as significant cost savings to the system. I would love to see a kind of two-way feedback between patients and their healthcare providers outside the hospital and the office. Right now, we often need to admit patients to the hospital just to monitor them, even if they aren’t presenting extreme clinical symptoms. Because when they go home I can’t monitor their heart rate regularly, or I don’t know what their heart rhythm is, I have to keep them in the hospital or have them come into the clinic daily so that I can get that information. That is incredibly disruptive for patients and caregivers. They shouldn’t have to keep coming back and forth every day.
The biosensor technology exists to acquire that information episodically or continuously from patients, in an unobtrusive way, at home. Doctors and healthcare organizations need to figure out a way to connect to that and work with our patients in their homes.
CSH: If remote monitoring and regular doctor-patient communication outside the hospital or clinic becomes the norm, what does the healthcare of the future look like?
SL: I see the brick-and-mortar facilities of healthcare shrinking. I see the expansion of social communities that will deliver care, with input from care providers into those communities. Of course, we will still identify certain people with acute problems that require brick- and-mortar facilities, but in general I see a system that is much more streamlined and efficient and community based than it is now.
CSH: Are physicians prepared for this shift?
SL: I think there will be a generational creep toward widespread acceptance of this new care delivery model. For example, most communication for my children is through social media, Instagram, and texting. This is just the way they interact – interacting socially, online. They’ve accepted the fact that there is this sort of faceless, voiceless communication, and that’s how they adapt. They get their information electronically. They’ve already bought into this, so it’s not novel to them. Many of today’s physicians, and certainly those of the near future will have grown up bought into this, and it will be second nature to communicate this way with patients.
It’s not about email and phone calls – it’s about a combination of the physiological information that is available about each of us through increasingly ubiquitous biosensors, as well as the virtual connectivity – for example through FaceTime – that will allow doctors to communicate and diagnose more efficiently because they can see the facial and hand gestures and all that sort of subtle communication that’s lost in an email or phone call. Yes we can get that in an office visit, but my point is that in the future it shouldn’t always require a trip to the office.
CSH: What’s preventing this kind of physician-patient communication now?
SL: Two things: payments and licensure. The system is currently set up so that reimbursement is primarily for tests and services provided in the clinic. Physicians and health systems are rarely reimbursed for services provided that are not in person or for taking the time and resources necessary to monitor remotely the health status of their patients.
Additionally, I need licensure in each state to practice medicine. Let’s say you’re my patient at the Mayo Clinic in Arizona, and then you go to Seattle for a few months and something happens. You call me on the phone and we engage in a bit of back and forth communication. But if we were to have a FaceTime call and I was actually to tell you what to do or to give you some healthcare advice, this may been deemed as practicing across state borders, and I would be in big trouble. Healthcare reform must address this, but of course state medical licensure is big business for each state. Good business for the state but perhaps not in the best interest of its population? I would love to see this issue further explored.
CSH: Are any systems already implementing the vision you laid out, unconstrained by payment or licensure?
SL: Well, I grew up and trained in Canada, which has an interesting national healthcare system. Not better or worse, just different. For example, Ontario, one of Canada’s provinces, has a huge land mass and large areas with small, scattered populations. There are small hospitals in the rural and northern areas of the province providing local healthcare but few specialists in these rural areas overall. As a result, in complicated cases or cases requiring specialist care, patients often have to travel many miles to large urban sites to obtain ideal care. Instead of paying for a patient to travel to the big city for a consult, investigation, or procedure, in Ontario there is increasing utilization of things like virtual communication tools (telemedicine and telehomecare) and robots to promote healthcare in the patient’s community. Things like telemedicine absorb a lot fewer resources, have high patient satisfaction, and I’d say that Ontario has great outcomes with it. When I saw that I said, “Boy, I could really do this here.” And I just decided I had to try.
CSH: And what was the reaction from your fellow physicians when you first proposed a big shift toward virtual communication and leveraging biosensors?
SL: Some physicians, often those who have been in practice for many years, said, “I’d quit before I would ever practice medicine like this.” Others embrace it more fully. But I think once people do it, they realize it’s really not so bad. It’s kind of like banking. People rarely go to brick-and-mortar bank facilities anymore; they do most things online or through ATMs. We don’t call it telebanking. Banking online is just banking. That’s just the way it is and has just evolved. I don’t really think of what I’m talking about as “telemedicine”. It’s just another way to practice medicine.
CSH: Are patients ready to embrace this vision?
SL: I think that many are. Because the way we practice medicine right now is inconvenient for them. For example, if you have a follow-up appointment with me, instead of driving down to the clinic, checking in early, and spending half a day for a 30-minute appointment, wouldn’t it be nice if we had a “virtual” appointment with video and could each chime in from our desks at home or in our offices at a set time?
In addition to being more convenient, this, too, promotes what I call “healthcare going green.” It’s decreasing the carbon footprint of healthcare—you don’t drive around, fly around, and so forth.
CSH: Biosensors produce a lot of information. If you have a FaceTime appointment, would you have had to go through spreadsheets or numbers recorded by my biosensor, beforehand?
SL: I think what will happen is that there will just be trigger alerts. So, if there is a change in the baseline then that would trigger an alert that comes across the caregiver’s or healthcare provider’s desk. It might trigger a call from a nurse or doctor or some other type of interaction back at the base. In other words, I wouldn’t be poring over hundreds of numbers for an hour before each appointment. It’s the changes that I am concerned with.
Let’s take heart rates, for example, or heart rhythm. When there’s a change to the normal pattern, a biosensor that has been taking episodic or continuous readings makes a note, and can send an alert. Then ideally the healthcare team goes back and tries to understand what happened at that moment and if any action is needed.
CSH: So patients’ biosensors would be remotely connected and programmed to send automatic signals to you. But surely you don’t plan on calling every patient who gains half a pound. How do you know which signals require a response?
SL: In most cases it’s more about a holistic picture of a patient’s physiology—not one specific reading. For example, patients could have electronic weighing scales, enabling me to see changes in their weight and their body mass and composition. That information, plus their pulse, blood pressure, sleep, neuroactivity, and number of steps per day, taken continuously, gives me a very good picture of overall health, and helps me understand what changes to that person’s “normal” should worry me.
CSH: To help us understand how to set up this system effectively, you are doing a study around biosensors and healthcare teams. Could you share a little background?
SL: The project is a tele-homecare pilot program where we’ve put together a care management team that includes physicians, a nurse practitioner, a social worker, an exercise physiologist and motivational interviewer, and a dietitian. We’re looking at a group of 40 patients with heart failure and 30 patients with atrial fibrillation, who we’ll follow for four months. Each patient has a biosensor that sends a set of measurements to us. Ultimately, we’re trying to get a feel of how to create effective healthcare teams, how to change unhealthy behavior, and how to facilitate communication with patients. We would love to rapidly scale this across our organization and support other health field communication with patients who have varied diagnoses.
CSH: Are there financial catalysts that make the project particularly timely?
SL: What’s happened is that Medicare has created a penalty. If patients with certain diagnoses—one of them is heart failure—are readmitted to a hospital within 30 days, not only do the healthcare organizations not get reimbursed for their services, but, eventually, Medicare will impose a penalty on all Medicare patients that have come into our hospitals. This penalty does two things. First, it inadvertently may extend the length of hospital stays; secondly, it increases costs. The consequence of the penalty is that one may rather keep a patient in the hospital for an extra day or two for monitoring even if each day carries significant financial costs, as opposed to worrying about the reporting and reimbursement consequences of that patient being readmitted.
The idea with the health team project is that we will be able to identify patients when they start to have a change in their health status, and we will be able to detect and deal with that before they end up back in my hospital. With this model in place, we hope that patients will be discharged in a more timely fashion without the concern of readmission. It’s good for patients and good for the system.
CSH: What does your healthcare team actually do?
SL: Our social worker makes sure we understand what the patient’s social environment is like so that we can take that into account. We have a motivational interviewer because we want to be able to understand behavior change. I want to know what makes people embrace the changes that are required to improve their health. Each of us watches the patients in different ways. Our goal is to help patients live longer, healthier lives. And a lot of what drives longer, healthier lives is behavioral change.
Machines themselves aren’t changing our behaviors. They can certainly be motivators, however. For example, I wear an activity tracker, and if I don’t reach a certain number of steps during the day you’ll find me taking walks at night, or walking while I’m on the phone.
CSH: What is the relationship between a patient’s social community and their behavior, or behavior change?
SL: Your behavior is influenced by your social community. If you live in a community of healthy people, then you tend to be healthier. These communities don’t need to be physical communities; in fact, our social communities are increasingly virtual. And people are going to get more and more health information from other members of their virtual community. What I want to do as a healthcare provider is to inject some evidence-based knowledge into that community.
CSH: You haven’t really talked much about the technology or devices themselves, why?
SL: That is because it is not about the machines. It’s about people. We’re using machine-to-machine connections and biosensors as tools, but the technology certainly isn’t the goal. One of my patients said, “It’s not Big Brother watching, it’s Big Doctor watching you.” I gained weight today, I didn’t walk today, or I didn’t sleep enough today, or whatever. Many of them have said that the knowledge that I am watching them serves as a motivator for healthier behavior. This may not positively motivate everyone, but that’s exactly what we want to understand about behavior.
CSH: How do you see Project HoneyBee complimenting your vision and work?
SL: I’m a physician; I manage patients and I simply use the technology. I’m not an engineer. I don’t have that background. While I’m a user of technology, I can’t create the technology. I can work with the Project HoneyBee team to infuse clinical needs such as by saying “It would be great if the device could do X, Y, and Z.” They can make it happen, and then I can implement it clinically and positively transform both the experience and delivery of healthcare.
CSH: What does your communication look like with the industry partners that are currently leading the way on biosensor creation? How might Project HoneyBee facilitate or improve that communication?
SL: Oftentimes, companies create some unique tool or product and then come to me and say, “Look at this great new thing that I have. Look at how you can use it.” And I respond: “Yes that’s a really neat tool, but what I really need is a tool that does this other thing.” What Project HoneyBee offers is a way for clinicians and health systems to lay out their needs, and for devices to be created or updated in response to that. This is very different from the way the market works currently.
I’m the Industry Relations Chair for the American Society of Echocardiography, so I work with multinational corporations, and at times the conversation tends to go the way I just described. The companies are trying to differentiate themselves in the market, so they create these tools. And I’m trying to create a sort of X-Prize in the imaging world to provide a forum for physicians, and technologists, and scientists to clarify what they need.
CSH: So in your opinion a key challenge is that device companies aren’t always seeking out the clinical questions physicians are asking, and then shaping the devices to help answer those questions. Are you hoping that Project HoneyBee connects device creation more effectively to clinical needs?
SL: Oh my gosh, that would be great. What excites me about Project HoneyBee and all the resources that ASU has is they provide an opportunity to articulate what I want, as a clinician, and then help companies understand that and make tools that meet those needs. Then we could refine it in the clinical world. ASU has incredible talent and resources, like behavioral therapists who can help us understand behavioral change. They have bio-engineers to create the products, and they have computer scientists, code writers, and all the people and things that we need to better connect our physiological, clinical, and electronic worlds. I think I know what I want. Project HoneyBee provides the team to help put it together.
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Written by Jason Cheatham