Vol. 185 January 15, 2018 New High Tech, Now and in the Future

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The start of a new year is a great time to look at some new medical technology and speculate a bit about how it might evolve.  This blog space is too limited to cover the inundation of new medical apps, so we will largely ignore them.

The title alone has an ominous ring, and that is not altogether an inappropriate feeling. A pharmaceutical company is testing a pill with a built-in sensory that can track AND REPORT ON whether or not the patient is taking a medication. The sensor is called an Ingestible Event Marker (IEM), which I think is only a slightly less ominous label. The IEM is activated when gastric contents reach it as the capsule dissolves in the patient’s stomach. The activated IEM sends a signal to a patch worn on the patients abdominal skin. The patch, in turn, alerts a cell phone app that reports the event to monitoring physicians. If the patient doesn’t take his medicine, of course, there is no electronic beep from the cell phone to the monitors. This gives the prescribing physician real-time data on the patient’s “adherence” to the prescription (used to be called “compliance”, but that was declared politically incorrect during the peak of concern with patient’s rights and autonomy). The same app can also track patient-reported activity, mood, and quality of rest. This package of new technology is called Digital Health Feedback system (DHFS), and, as you might guess by these tracking elements, this clinical test involved patients with a mental illness, schizophrenia to be exact. As one reviewer commented, “”It is ironic that this technology is being piloted with a drug used for paranoia.” (NEJM, Jan. 11, 2018, pg.101)

We are assured that the use of this technology is completely voluntary, and the patient can remove the reporting patch anytime they wish. A preliminary study of 28 patients using the IEM pill found that 27 completed the study, 24 of them thought that the technology would be useful to them, and 21 said they would like to receive reminders on their own cell phone if they forgot to take the medicine. (Ibid)

Despite the apparent compliance with this adherence pilot test, I can imagine how this might evolve in association with other new technology:
Alexa at 8:00 AM – “Good morning Herbert. Today’s weather is going to be unseasonably warm, you have a 10:00 AM appointment in your office, and be sure to take your high blood pressure pill after you eat breakfast.”
Alexa at 12:30 PM – “Keep up the good work Herb. You have only one scheduled appointment this afternoon, and I notice that you haven’t taken your blood pressure pill yet.”
Alexa at 5:30 PM – “Now Herb, remember that this pill should not be taken with alcohol. I know it must have been a hard day, but you don’t want to make it any harder on your body.”
Alexa at 8:30 PM – “Hey Herb! Not only have you not taken your pill, but I noticed that you skipped your regular visit to the gym today. Wha’sup? By the way, congratulations on your Weight Watchers dinner tonight.”
Alexa at 11:45 PM – “HEY STUPID! You forget to take your pill ALL day. Take your pill NOW, turn off Colbert, and go to sleep. Your family is counting on you, … not that I care, of course.”

Kaiser Permanente, the large California-based health system, reported that last year a majority (52% actually) of their 100 million patient encounters were “virtual visits”. (NEJM, Jan. 11, 2018, pg.104)  Virtual visits involve secure email and video engagements. Patient portals into medical offices, use of Skype, and teledermatology programs are familiar virtual tools. Telemedicine that allows monitoring of blood pressure, weight, blood glucose, and even EKG for home-bound patients with chronic disease are commonplace now. Future innovations could include cell apps that monitor the “total hours spent in high-allergen zones” for an asthma patient, or that deliver “intensive behavioral counseling” to people with obesity-related disease (“HERBERT! Step away from that refrigerator!”), or that make assurances that the patient’s near-empty automated pill dispenser (remotely monitored by the pharmacy, of course) would be filled soon by a forth coming home visit.

One author suggests that in the future “a face-to-face, in-person encounter would be reserved for the patients with the most health care needs – the 5% that account for 50% of costs. In-person encounters would become Option B”. (Ibid)  Obstacles to such progress could be patient fears of getting trapped in endless “phone menus”, lengthy voice message instructions, or numerous, sequential mouse clicking. Physicians might fear being marginalized, and, of course, no one is currently paying for these virtual encounters. A future evolution to mostly virtual visits would require a significant reorganization of and changes in reimbursement of medical care delivery. Kaiser Permanente’s virtual visit capacity is supported by the 25% of its annual $3.8 billion capital budget it spends on information technology.

Though I am tempted, I won’t go into what might happen if a future patient portal, an automatic pill dispenser, and Alexa signals got all mixed up together by mistake. Might a patient request for a 10:00 AM home visit on Tuesday result in 1000 AMbien pills being delivered to the patient’s home by AMazon on two days?



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