Smartphones and Medical Practice 2.0

Reports abound regarding the pervasive, ever accelerating adoption of Web-based technologies such as smart phones, Facebook, and Twitter. McKinsey reports that over 4 billion people globally now use cell phones, and 450 million have a Web-equipped phone. ¹J. Bughin, M. Chui, and J. Manyika: “Clouds, Big Data, and Smart Assets: Ten Tech-enabled Business Trends to Watch,” McKinsey Quarterly, August 2010. Facebook now reports having over 500 million active users, ²http://www.facebook.com/press/info.php?statistics. and Twitter signed up 100 million new users in 2010. ³http://mashable.com/2010/12/16/twitter-stats-2010/. Younger generations in particular exemplify the dramatic changes to lifestyle, socialization, learning, and careers driven by these technologies. Forrester Research found that in September 2010, members of generations “X “and “Y” spent an average of 17 hours a week online. ⁴J. Anderson: “The State of Consumers and Technology Benchmark 2010,” Forrester Research, Sept. 21, 2010.

On the other hand, physicians generally have been characterized as laggard adopters of computers in their professional practices, as exemplified by the very slow implementation of electronic medical records. Over the last couple of years, however, “killer apps” designed for physicians are emerging and transforming medical practice in surprising and still evolving ways. The “killer apps” are used on “smart phones” powered by a broad array of mobile Web 2.0 tools. The health care industry refers to the use of Web 2.0 social networking tools as “Health 2.0.” One industry commentator said, “Health 2.0 leverages social software to promote collaboration among patients, caregivers, medical professionals, and other health stakeholders.” ⁵M.C. Domingo, “Managing Healthcare Through Social Networks,” Computer, July 2010.

The ‘Killer Apps’

“A smartphone is a device that lets you make telephone calls, but also adds in features that you might find on a personal digital assistant or a computer,” according to About.com. ⁶L. Cassavoy, “What Makes a Smartphone Smart?” About.com Guide. Common features include an operating system supporting applications, web access, a QWERTY keyboard, messaging capabilities, and software for editing documents and photos, managing music, and navigating using the geospatial positioning system (GPS).

A recent survey of primary care clinicians showed that “64% of physicians report owning a smartphone and those using their smartphone daily for clinical tasks are more likely to be active, peer influencers.” ⁷“PriMed Survey Reveals Daily Smartphone Users are More Likely to be Peer Influencers,” PriMed, Nov. 29, 2010; available at http://www.pri-med.com/PMO/DocumentDisplay.aspx?id=202842. “By 2012, all physicians will walk around with a stethoscope and a smart mobile device, and there will be very few professional activities that physicians won’t be doing on their handhelds. Physicians will be going online first for the majority of their professional needs and will be regularly pulling online resources into patient consultations,” said Monique Levy, senior director of research at Manhattan Research. ⁸“Physician Smartphone Adoption Rate to Reach 81% in 2012,” Manhattan Research, Oct. 5, 2009.

And it is not just the younger generation of physicians—59 percent of those over 55 years old are using smartphones, a rate over twice that of the general consumer public. ⁹“PriMed Survey Reveals Daily Smartphone Users Are More Likely To Be Peer Influencers,” PriMed, Nov. 29, 2010.

Research further indicates that the profile of high-use smartphone-using physicians is ideal for biopharma marketing, ¹⁰Id. as they differentially:

• see a higher number of patients,
• try new treatment options,
• influence peers/give advice, and
• are less resistant to visits by pharmaceutical company sales representatives.

Physician Adoption

There are a multitude of drivers underlying clinicians’ swift embrace of smartphones. Physicians initially followed their patients to the Web as the explosion of health information created transparency, confusion, and self-diagnosing. Further, physicians realized their reputations were being affected in some cases by Web chatter, and that they could gain some control by entering these discussions.

Likely more critical factors in attracting clinician interest include the technology’s potency for improving patient care and providing new ways of interacting with peers and patients, for example, collaborative, Health 2.0 tools. Research by Google and Manhattan Research found that the majority of physician smartphone users consider the device “essential to their practice.” ¹¹Bunny Ellerin, “The Social Physician,” Ellerin HealthMedia, November 2010.

Perhaps the biggest draw is the veritable “Wild West” of medical smartphone apps—Ellerin reports that as of November 2010 Apple’s iPhone store lists nearly 3,000 apps devoted to medical topics. ¹²“Social Media Boot Camp,” Ellerin Health Media presentation, Nov. 17, 2010. Apps range from medical and pharmaceutical references (the top two are Epocrates and Medscape), to diagnostic support, digital imaging, and remote patient monitoring. ¹³“Taking the Pulse,” Manhattan Research, Nov. 10, 2010. One market research firm projects the market for mobile health apps (mHealth) in enterprises such as hospitals to reach $1.7 billion by the end of 2014. ¹⁴“mHealth in the Enterprise: Trends, Opportunities & Challenges,” Chilmark Research, November 2010.

The social, collaborative, “2.0” mobile tools have emerged serendipitously at a time of great physician dissatisfaction with the practice of medicine, given the changes of the past 10 to 15 years. Dr. Val Jones, a physician blogging pioneer, explains that many physicians are using these tools because “They are frustrated. They need an outlet, they want their voices to be heard.” ¹⁵Bunny Ellerin, “The Social Physician,” Ellerin HealthMedia, November 2010. These mobile tools allow them to connect with peers, patients, and the public throughout the day, and share medical knowledge, images, questions, clinical cases, musings, and ideas.

Collaborative 2.0 tools include blogging, Twitter, Youtube, Facebook, LinkedIn and other social networking communities. Twitter is a micro-blogging and social networking service whereby users dispatch tweets (140 characters or less) to others who have elected to follow them. Mobile online communities are reportedly accessed by 36 percent of physicians to connect with peers. ¹⁶“PriMed Survey Reveals Daily Smartphone Users are More Likely to Be Peer Influencers,” PriMed, Nov. 29, 2010; available at http://www.pri-med.com/PMO/DocumentDisplay.aspx?id=202842.

Examples of physician communities include Sermo, with 112,000 members across 68 specialties as of March 2010, Ozmosis, DoctorNetworking, Medscape’s Physician Connect ,and the Endovascular Forum, with almost 13,000 interventional and cardiovascular specialist members. ¹⁷E.S. Fishman, “Physician Online Communities: Physician Social Networking and the New Online Opinion Leaders,” Manhattan Research, 2008. Sermo and Physician Connect offer free membership to physicians, and generate revenues from pharmaceutical companies and other organizations interested in accessing physician discussion content.

Hospitals also are eagerly creating collaborative 2.0 tools that can be accessed by smartphones—as of November 2010, 890 hospitals had established 2,337 social media sites. These included 437 YouTube channels, 701 Facebook pages, 662 Twitter accounts, 431 LinkedIn accounts, and 106 blogs. ¹⁸Ed Bennett, Director of Web Strategy for the University of Maryland Medical System, “Found in Cache,” http://ebennett.org/.

Medical Practice 2.0

Clinician smartphone adoption and the panoply of advanced apps available have both now reached a critical mass that is reshaping how “mobile” physicians practice medicine. A wave of doctors has now advanced beyond periodic use of “must have” apps and has begun to reformulate cognitive and physical workflows as well as personal interactions into what is likely to become a new mode of practice—“Practice 2.0.”

Practice 2.0: Knowledge

One of the most basic ways smartphones can affect practice is to serve as a medical knowledge repository accessible in real time, anytime, anywhere. This serves a critical need, as “the practicing physician requires assistance to assimilate and apply the exponentially expanding, often contradictory, body of medical knowledge.” ¹⁹A.D. Sniderman and C.D. Furberg, “Why Guideline-Making Requires Reform,” Journal of the American Medical Association, 2009;301(4):429-431. In fact, 54 percent of physicians surveyed by SDI Research reported using their mobile device during patient visits to access medical information. ²⁰“Mobile & Social Media Study: Physicians’ Views of Emerging Technology,” SDI, Plymouth Meeting, Pa., March 2010. Some reports indicate that this information is positively affecting performance. For example, a Brigham & Women’s Hospital study of Epocrates users found that 60 percent of physicians reported avoiding three or more errors a month by using that application. ²¹“Brigham & Women’s Hospital Study Shows Doctors are Taking Action to Improve Patient Safety and Care,” Epocrates press release, Dec. 9, 2005; available at http://www.epocrates.com/company/news/10233.html.

Further advancing the medical knowledge pool are the “collective intelligence” networks represented by physician online communities. These collaborative, virtual brains can “think” in advanced ways, as discussed in books such as “The Wisdom of the Crowds,” ²²J. Surowiecki, The Wisdom of the Crowds, New York: Anchor Books, 2004. and harnessed by companies like Innocentive. ²³http://www2.innocentive.com/. In an article in Computer, M.C. Domingo describes the potency of this model in medicine:

“In a physician social network, physicians exchange views about drugs, devices, and treatment options and can use their knowledge from daily practice to ask and answer specific clinical questions that are not obvious in the medical literature. The premise is that gathering and sharing information about new clinical findings, drug treatments, and patient care can bring unprecedented benefits to the medical community: physicians can better solve problems, collaborate on difficult cases, and predict future events through a network than they could individually or even in a small group.” ²⁴M.C. Domingo, “Managing Healthcare Through Social Networks,” Computer, July 2010.

Practice 2.0: Monitoring

Another way smartphones affect practice is through their simplification of remote patient monitoring. Mobile devices are equipped with a wide and growing array of sensors and imaging capabilities, and when layered with intelligent analytics and alert software can free physicians and nurses to care for other patients, enable longer distance care, and support patient self-management. These apps typically are specialty specific, for example, in emergency medicine the “Vigilance” app alerts physicians when patients are in distress and provides live videos from exam rooms and operating rooms. ²⁵J. Sarasohn-Kahn, “How Smartphones are Changing Health Care for Consumers and Providers,” California Health Care Foundation, April 2010. Also, a very popular obstetrical app, “AirStrip OB,” provides remote access to fetal tracings, contraction recordings, and nursing notes. Finally, radiologists have a mobile PACS imaging platform with the “OsiriX” app. ²⁶Id.

The sensor capabilities of smartphones have just begun to be tapped. Many of today’s smartphones include an accelerometer and gyroscope (combined, these two can sense motion along six axes), a GPS, microphone, and camera; much more is to come as the relentless technology drive toward smaller and cheaper continues. Peter Bentley, a researcher who created the “iStethoscope” app that recently was downloaded by 3 million physicians, extols smartphones as capable of saving lives, saving money, and improving health care in a dramatic fashion, and envisions the devices’ evolving into mobile vital signs monitors with “fully fledged integrated designs capable of taking ultra sound scans or monitoring a patient’s blood pressure.” ²⁷N. Martinelli, “Three Million Doctors Download iPhone Stethoscope App,” Cult of Mac blog, Aug. 31, 2010, available by searching at http://www.cultofmac.com.

Practice 2.0: Support

Interactions and relationships with patients are evolving as physician mobile Internet tools disseminate. For example, one physician blogger, Dr. Jennifer Dyer (Twitter name @EndoGoddess), found that “I didn’t know quite as much about the day-to-day struggles my patients deal with constantly. This has given me the opportunity to see how they handle it all.” ²⁸B. Ellerin, “The Social Physician,” Ellerin HealthMedia, November 2010.

The broadcasting power of the Internet has enabled clinician bloggers to reach surprisingly large numbers of “information patients” hungry for a physician’s interpretation of medicine’s complexities. Dr. Kevin Pho of KevinMD.com records over 300,000 page views a month by providing his medical perspectives on health topics in the news. ²⁹ Id.

Mobile phones also provide physicians a platform for connecting with their patients between visits to facilitate treatment adherence, coordinate care, and promote self-efficacy. Ellerin reports that Dyer is using mobile 2.0 with her teen diabetics—“She launched a texting ‘reminder’ program using an iPhone app that allows her to send personalized messages in addition to standard questions. The results of the study have been positive; Dr. Dyer saw a significant improvement in medication adherence over a three-month period.” ³⁰Id.

In fact, according to one review, 93 percent of medical text-messaging interventions produced positive behavioral changes. ³¹B.S. Fjeldsoe, A.L. Marshall, Y.D. Miller, “Behavior Change Interventions Delivered by Mobile Telephone Short Message Service,” Am J Prev Med. 2009;36(2):165–73. These tools also are being deployed in developing countries like Mexico, where the “VidaNET” mobile phone application supports HIV patients by sending text message reminders about taking medications, keeping appointments, and how to find additional support. ³²J.L. Feder, “Cell-Phone Medicine Brings Care to Patients in Developing Nations,” Health Affairs, February 2010, vol. 29, no. 2, pp. 259-263.

Implications for Industry

Smartphone technology is racing ahead and a substantial number of physicians have jumped aboard and are experimenting with a “Wild West” of applications. These mobile tools offer myriad novel channels for touching, dialoging, and even collaborating with physicians and patients throughout the life cycle of drug development.

Twitter and medical online communities both are being used as platforms for clinical research, initially as recruiting tools and more recently for data collection and mining. For instance, Twitter smartphone apps used during trials can be mined for patient activity, physiologic monitoring, and messaging data to explore interesting relationships or potential additional indications.

Further down the evolutionary path, industry is experimenting with 2.0 networking tools for new types of clinical research studies. For example, PatientsLikeMe ³³http://www.patientslikeme.com/. comprises online communities of patients with life-threatening diseases who share information with one another. Through these interchanges, ideas for new treatment approaches sometimes emerge, such as in early 2008 when lithium was considered for amyotropic lateral sclerosis (ALS). PatientsLikeMe began collecting data from its members, in a manner described by one of the founders, Jamie Heywood, as “the first real-time, real-world, open and nonblinded, patient-driven trial. We believe we will have the power, within months, to begin answering the question of how much lithium modifies the progression of ALS.” ³⁴M. Allison, “Can Web 2.0 Reboot Clinical Trials?” Nature Biotechnology, October 2009, vol. 27, no. 10.

Another venture, CollabRx, ³⁵http://collabrx.com/. has created “Cancer Commons, a family of open-science cancer communities in which physicians, patients, and scientists collaborate on models of cancer subtypes toward the goal of more accurately predicting individual responses to therapy.” As their white paper states, the Web’s ability to network and rapidly update is critical to the venture—“The key innovation is to run this adaptive search strategy in “realtime,” continuously updating disease and treatment models so that the knowledge learned from one patient is disseminated in time to help the next. ³⁶“Cancer Commons: Winning the War on Cancer One Patient at a Time,” CollabRx whitepaper, October, 2010, available at http://cancercommons.org/Cancer_Commons_Whitepaper.pdf.

A bit further out, when Twitter meets medical smartphones interfaced to electronic medical records (EMRs), these mobile networks will provide a quantum leap in generating new medical discoveries through the mining of secondary data. Infectious disease surveillance systems are just one possibility. Far more interesting will be the epidemiological and behavioral research studies that can now only be imagined.

Marketing in this new mobile frontier offers countless blue sky opportunities. A major caveat here is the Food and Drug Administration, which has yet to issue long-promised rules regarding marketing using 2.0 platforms, yet periodically disciplines companies for doing so. ³⁷For example Novartis’ Facebook widget for leukemia drug Tasigna—see http://worldofdtcmarketing.com/fda-demonstrates-their-ignorance-of-social-media-with-letter-to-novartis/social-media-and-healthcare/.

Pioneering biopharmaceutical companies can form entirely new relationships with physicians by exploring very different sorts of marketing programs. In keeping with the culture of this 2.0 mobile world, smart industry participation would be transparent, nonintrusive, and, most importantly, provide value to users. Eventually, many in industry predict detailing will move largely to mobile platforms. ³⁸L. Starnes, Bayer Schering, “Healthcare Professionals’ Social Networks—The Beginning of the End of Pharma Marketing as We Know it?” Digital Pharma Europe, Barcelona, March 31, 2009.

Initially, industry is creating value-added mobile apps for their products, such as those that support prescribing and adhering to treatment regimes. For example, Novartis has created an Oncology Medical Information mobile app that provides physicians with prescribing information, a medical search function, and the ability to submit a medical inquiry. ³⁹http://www.novartisoncologymedinfo.com/. A more creative though technically primitive Novartis app for consumers is their WheresFlu™ app. The app tracks cold and flu incidence levels from week to week, and allows users to enter their ZIP code and find levels for their area, as well as the current top five affected cities in the nation. ⁴⁰http://www.androlib.com/android.application.wheresflu-com-qtqxD.aspx.

Pharmas also have begun participating and sponsoring online communities, with mixed success. Regulatory issues are a continuing hindrance, making open, spontaneous dialogs directly between industry and physicians complicated. Examples include several brand-sponsored patient communities—Accu-Check Diabetes Link (Roche), Children with Diabetes (J&J Lifescan), Crohn’s and Me (UCB), Diabetes Handprint (J&J Lifescan), and Voices of Diabetes (Novo Nordisk). ⁴¹http://pharmamkting.blogspot.com/2010/04/pharma-social-networks-close-but-no.html. Pfizer has partnered with Sermo for the past three years, and appears to be exploring a number of creative programs. Most recently, Pfizer, Sermo, Epocrates, and Brigham and Women’s Hospital teamed up on a project named Aster (Adverse drug event Spontaneous Triggered Event Reporting) that facilitates reporting of adverse events by automating their submission from EMRs. Arnold reports that “The system also collects more information about a patient’s background in order to make it easier to determine whether an adverse event was caused by a drug or some other factor.” ⁴²M. Arnold, “Pfizer Seeks Ways to Ease Adverse Events Reporting Digitally,” Medical Marketing & Media, March 30, 2010.

More generally, pervasive mobile networks will serve as channels for market data capture by biopharmas to listen to the medical marketplace pre-launch, virally disseminate awareness upon launch, open dialogue during growth, and use real-world observations to respond and adapt during the drug life-cycle. ⁴³L. Starnes, Bayer Schering, “Healthcare Professionals’ Social Networks—The Beginning of the End of Pharma Marketing as We Know it?” Digital Pharma Europe, Barcelona, March 31, 2009.

Conclusions

A critical mass of physicians has now elected to use smartphones as their central medical electronic platform—for knowledge, data, communication, and advanced functionality. Two aspects of this phenomenon are striking and surprising—the speed with which clinicians are integrating the technology into their practice and their willingness to try apps that offer entirely novel functionality. Great opportunities appear to lay in store for those biopharmas that can swiftly create equally novel ways to reach and collaborate with these clinicians in cyberspace.