How Much Health Should Flow Through Your Smartphone?

We at KBGH get pitched a lot of apps. Apps for blood pressure, apps for blood sugars, apps for lab and imaging pricing. Lots of apps. In the roughly two years that the current staff has been at KBGH, I think pitches from outside companies have covered most of medicine in apps, save a few small nooks and crannies. I don’t think we’ve been pitched a fertility app yet, for example, but I might be mistaken. And this isn’t an ivory tower problem for us; we’re in on the creation of apps as well. We’re working with WSU’s College of Innovation & Design on a Rural Health Challenge to, in part, help connect rural patients with their doctors via technology. That technology may include smartphone apps since, according to a Cochrane review, there is “low-certainty evidence of the effects of mobile phone-delivered interventions to increase adherence to medication prescribed for the primary prevention of [cardiovascular disease].”

But, as we’ve blogged about before, your computer or smartphone may not be the most direct route to a healthy, happy life. Excess time on devices, particularly that spent on social media, may be bad for us and may paradoxically exacerbate loneliness and isolation. So how much of our medical care should run through our phones? I’m generally optimistic about the future of telemedicine, but I’m pessimistic about the attention economy, in which companies are incentivized to grab increasingly big chunks of our time.

Regardless of my opinion, though, people have thought hard about what should go into a good medical application. Here are four elements paraphrased from Swiss investigators Kenny R. Lienhard and Christine Legne:

  1. Mobile medical apps should guide a patient through every step of instruction, setup, clinical measurement, and analysis and feedback. Imagine that you just downloaded an app to your smartphone to help communicate blood pressures to your doctor. The app shouldn’t just tell you how to send the blood pressure. It should give you instructions on the technique for where to place the cuff. It should provide feedback if it senses your technique is wrong, like if different readings get very different results. It should help you analyze the numbers; if your blood pressure is consistently high or low, it should prompt you to talk to your doctor about it.

  2. The user interface should be adapted to cope with patients’ physical and cognitive restrictions. This goes without saying. The American Medical Association (AMA) recommends that health care materials be written at or below a sixth-grade reading level. But the interface should also account for people with impaired vision or hearing or differences in dexterity, to name a few.

  3. A mobile medical app should build on a robust medical knowledge base, ensuring an evidence-based approach to mobile app design. This one is tougher because most of us–present company included–don’t necessarily know the ins and outs of app design. But manufacturers can search out the best medical advice for many circumstances and account for those in the testing of the app.

  4. Mobile medical apps should facilitate both patients’ and physicians’ routines. This is crucial, and it applies directly to work we’ve done at KBGH. It is great to get blood pressure results to your doctor. But it’s even better if the app, upon seeing those blood pressure results, can make a treatment recommendation to your doctor. We call this “decision support.” The app may give bad advice once in a while, like recommending a thiazide diuretic for a gout patient, but making more sophisticated decisions is what the doctor is there for.

What experiences have you had with medical apps? Let us know!

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on hot topics that might affect employers or employees. This is a reprint of a blog post from KBGH.

Is social distancing...bringing us closer together?

As the Medical Director of the Kansas Business Group on Health I’m sometimes asked to weigh in on topics that might affect employers or employees. This is a reprint of a blog post from KBGH:

If you’ve read as much as I have in the last few days about the COVID-19 pandemic, you’ve probably come across ominous-sounding warnings about social isolation or loneliness as a result of social distancing, our preferred short-term strategy to prevent the spread of the SARS-CoV-2 virus. Social isolation is the physical state of being alone, while loneliness is the feeling you get when your social interactions don’t meet your expectations; you can feel lonely in the middle of a crowded room, but you’re only socially isolated when you’re, well, socially isolated.

But both are bad for you. A 2017 systematic review showed that social isolation was associated with a 29% increased risk of death, while subjective loneliness was associated with a near-identical 26% increase in mortality. For perspective, a second meta-analysis in 2010 showed that “…by the time half of a hypothetical sample of 100 people has died, there will be five more people alive with stronger social relationships than people with weaker social relationships.”

As we have ramped up social distancing there has been legitimate fear that we would exacerbate the already-high rates of social isolation and loneliness, especially in elderly people. While it’s too early to say if that’s happening, I’ve been pleasantly surprised at my own experience. Just yesterday this meme came across my phone:

quarantine-meme.jpg

I found it so true. Now that many of us (but not healthcare workers, first responders, food delivery people, restaurant workers, mail carriers, or a hundred other “essential service” professionals and workers) are stuck at home during the day, it seems that we’re finding new strength and resilience just from getting out and moving in our neighborhoods and green space. I’ve talked to more neighbors on walks in the last three days than I had in the last three months, and not just because of warmer weather. Could it be that COVID-19 has begun a small restoration of what physician sociologist Nicholas Christakis calls the “social suite”: love, friendship, cooperation, and teaching, all from six feet away?

The evidence of increased investment in the social contract isn’t limited to the streets in my neighborhood. Young people are volunteering in large numbers to do things like deliver meals. So many retired doctors have offered to re-enter the workforce–at significant personal risk, considering many of their ages–that the Kansas State Board of Healing Arts has begun issuing emergency short-term licenses, and KAMMCO is issuing short-term liability insurance. Manufacturers in cycling, my favorite sport, are pivoting away from bike gear and toward the production of personal protective equipment. Congress is operating at a rare, near-normal level of functionality to give financial relief to millions of people (now if we could only get more testing resources). And I know that many of the readers of this blog, be they human resources professionals, insurance brokers, health administrators, or others, are working steadfastly to save as many jobs at their companies as they can in the face of an impending global economic catastrophe.

While you’re working hard on those things, don’t forget to work on these, too:

1. Look for ways to have “conversation-centric” interactions with people. Talk on the phone. Skype or FaceTime. Talk to people from your porch or from the street. As former Surgeon General Vivek Murthy says, “Smiling at someone–eye contact–is an act of service.”

2. Let kids around you continue to have unstructured play time with friends. Just keep them apart. Let them run around, ride bikes, and throw sand. Don’t let them wrestle or share toys.

3. If you’re still going to work, synchronize your coffee breaks with someone else. Common socializing like this has been definitively shown to be more restorative than snacking or emailing. If you can do it outside, even better.

4. Take time to express gratitude to others. Expression of gratitude is one of the most common indicators of life satisfaction in the US.

5. Volunteer. Organizational volunteering has been shown to be associated with a 24% reduction in mortality risk.

6. If you’re lucky enough to have some money to donate, do it. Spending money on others makes us far happier than spending it on ourselves.

Are friends for hire a solution to loneliness?

Just out of college, one of my friends quit his good-paying, stable job at a big midwestern company to start a "jack of all trades" handyman business. He and another of our college friends mowed lawns, rebuilt decks damaged by tornadoes, repaired drywall, fixed sprinkler systems, and did other odd jobs. General handyman stuff. 

One day he was called to a house to change light bulbs. This was a common call; it was easier for people to call him than to get their own ladder and defy death above a stairwell. When he finished, the elderly lady who'd called him offered him a glass of water and a seat while she paid the bill. 

"How much would it cost to have you here weekly?" she asked. Again, this wasn't an uncommon request. Many people kept him on retainer and had him come by periodically to do little jobs. My friend eased into his spiel about the packages he had available, and what services were available at each price point. 

"No, no," she said. "How much would you charge just to come by and talk?"

I don't know what happened after this. Every time I heard him tell the story it ended there with all of us groaning about how sad it all was. How sad that an old lady was so lonely that she was willing to give money for company. The reason I bring the story up at all now is that I just read "How to Hire Fake Friends and Family" by Roc Morin in The Atlantic. 

"[Ishii Yuichi]'s 8-year-old company, Family Romance, provides professional actors to fill any role in the personal lives of clients. With a burgeoning staff of 800 or so actors, ranging from infants to the elderly, the organization prides itself on being able to provide a surrogate for almost any conceivable situation."

Some details are heart-wrenching: single moms hiring men to pose as Dad so they aren't discriminated against. Some of them are creepy: one of those single moms has never broken it to her daughter that Yuichi isn't her real dad after eight years. Some of them are downright strange, like this example of surrogacy that seems right out of an Uday and Qusay tale:

"Usually, I accompany a salaryman who made a mistake. I take the identity of the salaryman myself, then I apologize profusely for his mistake. Have you seen the way we say sorry? You go have to down on your hands and knees on the floor. Your hands have to tremble. So, my client is there standing off to the side—the one who actually made the mistake—and I’m prostrate on the floor writhing around, and the boss is there red-faced as he hurls down abuse from above."

Because of the "Romance" in the company name, I suppose, and to head off the inevitable comparison to prostitution, no, Yuichi and his workers do not provide sex. He claims that they aren't even allowed any physical contact besides hand-holding.

I've written several times in the short life of this blog about the dangers of loneliness. I've spoken about it even more. So this post isn't meant to poke fun at the sometimes bizarre social norms like this that crop up in Japan. They may only be bizarre to my western eye. After all, much of what we do in medicine, particularly in palliation, boils down to the act of being present for a person. And sometimes that's the hardest thing of all. My friend didn't take the lady's money for his company. But even if he had, I think we could argue he'd earned it. 

In the words of Yuichi himself, "It feels like work to care for a real person."