Dr. Topol: EMRs remind me of the Tower of Babel

By Brian Dolan
08:02 pm
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Dr. Eric Topolmobihealthnews had a chance to sit down with Scripps Health's Dr. Eric Topol, who is also Chief Medical Officer of the recently founded West Wireless Health Institute, on the sidelines of the Wireless Life-Sciences Alliance meeting here in La Jolla, California. Topol explained why he disagrees with Gartner analyst Wes Rishel, why EMRs are like the story of the Tower of Babel, how PHRs aren't much better and why the Obama Administration needs to learn about the revolutionary potential of wireless sensors today.

mobihealthnews recently wrote a commentary on a story that quotes Gartner analyst Wes Rishel as saying that technologies like the heart sensor patch that you demonstrated at the CTIA conference are "incremental advances" and that the the real revolution in health care IT will likely come from increased deployments of electronic medical records systems and the resulting improvements in data-sharing among organizations. Any response to that?

I certainly respect his opinion -- and I don't know him -- but I couldn't disagree more. On the one hand, electronic medical records and getting health IT systems to share medical record information is the most formidable challenge of all. But on other hand, all of these exciting wireless healthcare technologies can be siloed in their development -- they don't depend on EMRs to be successful. In fact, most of these wireless sensors work perfectly well without any electronic medical record at all. What is amazing about these technologies is that they generate so much information about the individual. In a perfect world, sure, it would be great to have everything integrated into a common record, but that's not needed for these wireless technologies to revolutionize healthcare. Look across the board at every type of disease: wireless health can address some of the symptoms of these conditions, lead to prevention of the disease or help with some of the complications.

At the CTIA event in Las Vegas last month you listed ten diseases or conditions that will soon or already being addressed to wireless health technology. You called these ten top targets for wireless healthcare. One of our readers wondered why wireless health services that helped prevent these diseases or conditions wasn't at the top of that list?

It is easier to start with people who already have manifested a condition. If you look at my top ten targets for wireless healthcare, asthma is on the list. Asthma can be life threatening. While people with asthma are generally fine, preventing a bad spell could keep them out of the hospital or even prevent their death. So, sure, it'd be much better to prevent asthma from ever occurring, but that's not likely to happen with wireless solutions.

If you couple wireless solutions with some of the work being done in genomics, however, you may be able to prevent some serious complications or in some cases maybe the conditions themselves. By screening people's genetic markers you can determine a predisposition to a condition or a serious complication. The examples for this are across the board -- genomics may indicate you are predisposed to have high blood pressure or obesity. Now, it's hard for wireless solutions to prevent someone from getting obese in the first place, but maybe we can use that information from the genetic markers and get this person using a calorie counter or exercise tracker early on.

The criteria for those top targets were that each had to be a major public health issue affecting a large number of people. There also already had to be some wireless solutions on the market or in the hopper that address the condition. That should be a major strategy though -- to prevent diseases. Wireless coupled with genomics can make a real contribution to that. We are capable of doing that today, but we are not doing it yet. I hope that soon becomes state of the art. Many of these wireless technologies and sensors are still in their earliest stages -- and genomics is too -- but both could have potentially steep adoption and the convergence between the two goes across the board.

Some remote monitoring services aim to automate everything while others are intent on having the user manually enter the information to keep them engaged. The automatic crowd seems bent on ensuring the technology helps make the monitoring a seamless part of their day, but the manual entry crowd believes automation takes the patient out of the care paradigm and could lead to less empowerment. Where is that balance between engagement and automation?

I think you want both, but you don't want to rely on patients to enter their own data. It doesn't work too well. As a cardiologist, I have patients that enter their blood pressure data and just fax or email it to me, but they don't want to do that. If I do get it, it's often an incomplete record. So, I'd like to see this information automated. On the other hand, we want to get that information available to the patient so that they can see it and so that it helps to empower them. We don't want to rely on individuals to manually enter anything, because it just doesn't get done efficiently.

This is especially true if you are doing continuous or near-continuous monitoring. In that case it's just impossible. Here's an example: If we want to monitor a person for a sleep disorder, they can't self report on sleep apnea spells [because they are asleep]. I have learned over the years that patients find having data about themselves to be just the greatest -- and it doesn't necessarily mean they are going to go out and lose weight or start exercising as a result, but there is at least now a greater potential for that. [Engagement comes in] when they turn on the phone in the morning and they will find the information has been sent to their phone. They will have no choice but to look at it. Maybe that information is also sent to a caregiver or their spouse's smartphone, too. It's also probably sent to their physician.

Microsoft HealthVaultAnother big point of contention is where this data should be stored. Most of these solutions have their own online portals so users can keep track, but Google and Microsoft are also pushing their own platforms as portals all of these services could eventually feed into. Do you see any value in the proprietary portals or is it eventually all going to find its way into a common one like Google Health or HealthVault?

We have had a lot of experience with personal health records. Right now at Scripps Health we're doing a big genomics project. Everyone involved, all 4,000 participants have set up a Microsoft HealthVault account as well, but it's very difficult as this point in time. Patients only have limited access to their medical information. They might have some dates on hand but they can't get a lot of reports or important images. They can only create a self-reporting PHR so it's incomplete, time consuming and not really worth it. This lack of coherence and lack of any integration right now is what's facing EMR and it's the same story with PHRs. It's like the Tower of Babel -- most of them can't communicate with each other and it's really a problem. When are we going to get out of that? I don't see it in the near future. Even billions of dollars from the federal government isn't likely to turn this around.

A common platform is the ideal and someday everyone should have all their records with them or accessible to them at any moment in time. The concept is great but getting there is really challenging. All the wireless sensor companies [and remote monitoring companies in general] have to deal with this fragmentation, so they have to design a strategy that works for them. [Meaning proprietary portals mostly.] I hope we get out of that soon, but I don't think we will. We are much more likely to see these wireless technologies get adopted and become common to use before the fragmentation of EMRs is solved. I think, though, that [remote monitoring] companies will work together and partner when combining their portals make sense -- like a combination blood glucose tracking portal and a calorie counter portal. These are just work around plans, though. That's what we deal with when we talk about EMRs.

Do you think wireless health has any role to play in the meaningful use debate going on now -- is there room to include connected devices in that definition and as part of that incentives package?

A colleague of mine, whom I have great respect for, David Blumenthal deserves a lot of credit for taking this on, especially since he had that great gig at Harvard. He is struggling with this term along with everyone else. There will be panels of people weighing in on the definition of this. I don't have a good sense of that yet and this is not an area in which I have expertise. I am an end user and an end user who is frustrated, but I would defer to the gurus on this one.

So what kind of government education are you and the West Wireless Health Institute planning on? What should the focus be on if not EMRs?

So far, it's somewhat of a missed opportunity. There is so much interest on the medical records side, but the excitement and more imminent revolutionary potential is on the wireless sensor side. If they get used then they will bring about the outcomes we all want -- improve outcomes, and improve costs. Even the economists are beginning to agree that these wireless sensors are a technology that can lower costs. That's rare since almost every new technology in medicine raises costs. So that's how the government could be enlightened. This is a fast, burgeoning area that can help us see improvements in health and also drive costs down. EMRs don't clearly have that result. We can spend a lot of money but it's still unproven if EMRs will reduce costs over the  longterm or reduce medical errors. Those are still concepts that are out there to be proven. In general, it's good that health IT is being pursued, but this area is a benign neglect. We will see if we can improve on that -- no matter what, we will make some inroads. Hopefully the administration will take notice.

Any updates on progress at the West Wireless Health Institute?

We are designing clinical trials and hope to have some ready to go in the next few months, for sure. We plan on opening our building by September 1. We have an event at the NIH in June and that will be a major meeting on telemedicine. We also intend to have meetings between those of us at the Institute and key players in the Obama administration around the same time.

We are also working on bringing in a team of engineers that will be engaged in sensor development and refinement of sensors. We are planning on liasing with a major research university and bringing in a team that includes senior engineers, post docs and graduate students. Our CEO search is ongoing and kicking into high gear.

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