This article is excerpted from Chapter 6 of The Next Generation of Disease Management: 2009 and Beyond, edited by Jill Brown and Al Lewis.
I am not a soothsayer but I daresay that it is a pretty easy bet that the future of DM will be tied to increasingly available and increasingly sophisticated technological improvements. So let’s take a look at what seems to be coming down the pike and maybe what might still be around the corner.
We start and end with the movement of data. The amount of that data has already grown exponentially and the thirst for more data and more types of data is continuing unabated. Places to store that data continue to get more efficient, larger, and cheaper, allowing the growth to continue. Warehouses in the hundreds and thousands of terabytes have been in existence for some time. Personal computers can come with a terabyte1 drive now, something that would have been considered unheard of even five short years ago. The databases of the future will hold much greater amounts of data in a smaller footprint; seamlessly integrate different types of data from a variety of different sources; and allow for “virtual” data warehouses and datamarts by seamlessly gathering and collating data from different and remote sources and creating a virtual picture of the data linked and integrated together. In fact, all of this can be done today. It just is not yet cheap, quick, and/or particularly easy.
The data of today are moved in a variety of ways that is also getting quicker, cheaper and easier over time. It moves over telephone lines, via fax machines, and using the interactive voice response techniques discussed previously. It moves over large and small wired networks with names like local-area networks and wide-area networks at speeds that even a few years ago were not possible. Increasingly, the data move wirelessly, through the “ether,” as it used to be called, using technologies such as wireless local-area networks, broadband wireless, and Bluetooth. What technology will be the next big thing is up for grabs, but it will doubtless follow the same pattern of quicker, cheaper, better, and easier that will allow the movement of ever larger volumes and types of data between devices, places, and platforms without the need for human intervention. Doubtless, too, it will still include things like telephony, in whatever form that takes in the future, but it will also increasingly focus on the use of devices — which are evolving into “smart” devices.
Some of the future in those devices is already here, but just is not yet well known, widespread, or heavily adopted. The devices that are common tools in today’s DM programs are already starting to become yesterday’s devices. New tools are being introduced daily, and there is starting to be some blurring of who is interested in and involved in these technologies, as is often seen as an industry matures. For example:
- Smart pillboxes already on the market not only audibly and/or visually remind people to take their medications but also track that usage and report it electronically to a data center through a telephone line or via wireless upload technology.
- Today’s implanted cardiac defibrillators contain electronics and communications technologies that allow data to be captured and uploaded indicating when and how the unit triggered a shock to the heart. The information also is tied to algorithms that can predict when a patient is getting worse and whether the implant is functioning correctly. The implant can have its parameters changed remotely, based on an assessment of the data generated by the unit. Medtronic, one of the leaders in the implantable medical device industry, already has links to a call center and is able to monitor over 100,000 patients who have implanted devices2.
- The reader is probably familiar with insulin pumps that have been around for a long time now, but may not be as aware that implantable tiny catheters, available since 2005, can monitor blood sugar levels by being placed under the skin.
- There is also a leather wallet available which not only does everything your standard wallet does but also has a single lead electrocardiogram (EKG) that can be triggered by simply holding the wallet against your chest. It can transmit a rhythm strip via telephone or cell phone almost instantaneously.
- Another device can actually analyze a tiny blood sample looking for blood changes indicative of a cardiac event (myocardial infarction or heart attack) as well as provide an EKG and symptom checklist that can be uploaded to a medical facility for rapid assessment, hopefully preventing a serious cardiac event. That same patient could also be instructed to self-inject with lidocaine (a local anesthetic also used to prevent certain serious heart arrhythmias) to prevent an arrhythmia on the way to the hospital, using an available device that is almost identical to an EpiPen (containing epinephrine and used for people prone to serious allergic reactions).
- A company in the United Kingdom has developed a small patch worn on the chest that can monitor a patient’s vital signs including respirations, oximetry (the amount of oxygen in the blood), patient movement, temperature and electrocardiogram.
All of this is available today and I do not doubt that there are more out there that we just have not heard about yet.
At the time that this chapter was being written, the giant computer chip maker Intel had just received clearance from the Food and Drug Administration to market its in-home personal health system. What is being called the Intel Health Guide was devised to allow medical professionals to monitor people with chronic conditions. It combines an in-home device with Web connectivity and a communications interface to allow for home monitoring of various conditions. Intel has already completed a number of pilot studies and is in the process of doing others. It is expected that the tool will be on the market in 2009. ADT Security Services Inc., the home security company, offers a monitoring service for elderly adults that allows them to use the existing connectivity, including voice communications, of their home burglar alarm system and ADT’s existing call-center structure to call for medical help should they need it while in the home. Walgreens, the pharmacy chain, is beginning to market a somewhat similar concept and service.
And therein lies the future of technology in the DM arena. To use a grossly overused term from the early 1990s, there has been a paradigm shift taking place. But perhaps the most interesting thing is that it is taking place somewhat quietly and naturally. That paradigm shift is away from the concept of technology being able to do something for you or in place of your having to do it to the concept of the technology as a tool to allow you to keep doing things for yourself. It is an important distinction, one that is changing not only the way that devices will be used, but the devices themselves.
The driving force behind much of this development is the aging of the American population and, in particular, those post-World War II babies called the “Baby-Boom generation.” Those folks who are now beginning to enter retirement in increasingly large numbers have been caring for their aging parents (who are living longer) and are looking forward to a future where they want to be able to remain independent, active, and healthy in their own homes. The concomitant increases in chronic diseases, the stress that an increase in older Americans will place on the entire medical infrastructure, our growing waistlines, and an increasing comfortableness with technology is bringing together a “perfect storm” of needs, desires, economic realities and quicker/better/cheaper technology that is set to take off.
What has started with a series of tools focused on monitoring elderly parents’ safety and daily well-being is going to rapidly morph into a system of connected technologies that will not only assist in but encourage healthy behaviors. These systems will also allow the early detection of changes that may indicate the onset of disease or the worsening of an existing condition and make sure that the needed information, not just data, is transmitted and gets to the appropriate place in order that it may be acted upon. The very human need and desire to live better and live longer and to remain active as an independent contributing member of society is driving the development of “smart” technology. And it is that smart technology that is the future of DM, both as an industry and in a much more global sense.
“Smart” technology and “smart” devices don’t just passively gather data and transmit it. They have the ability to interact with the data and with other devices to not only allow the monitoring of everything from vital signs to blood chemistries to heart rhythms but also the way someone is walking or talking or the amount of exercise they do (or don’t do) and the food choices that they make. They can find patterns in seemingly unrelated things and may hold some promise for early identification/diagnosis of some diseases. They can learn over time and they can share the data and the learning with other devices, centralized or remote monitoring stations or networks and, of course, with medical professionals. They can give warnings, they can provide advice, they can tell you it’s time you get yourself to your doctor, or they can help prevent an unnecessary doctor visit. And if you do need to go, they can help your doctor figure out what is wrong with you more quickly.
This is not rocket science, either. Some of this is already available today. A toilet that monitors the chemical composition of your urine and feces looking for metabolic or other problems has been available as a consumer item in Japan for a number of years. Intel and other technology companies such as Honeywell have been working on building “smart” homes using today’s technologies to allow these “smart” tools to be linked with a variety of sensors built into the home itself to allow the monitoring of elderly individuals. Intel has extended this to include things such as motion detectors, pressure sensors in furniture, cameras, transmitters embedded in common household items, and sensors in carpeting, walls, and even clothing. All these tools can communicate with each other and through a network to allow a picture of an elderly person’s activities to be built and monitored for changes in routine that may indicate someone getting in trouble. The Defense Advanced Research Projects Agency (DARPA)3 has developed a T-shirt that a patient can wear that allows nonintrusive remote monitoring of vital signs. The nonintrusive part is the key, as it is the ability of these smart devices to do their work without being obvious and without interfering with the day-to-day activities of people that will allow the widespread usage and acceptance of these devices.
What else might be coming? According to Carol Lewis, author of Emerging Trends in Medical Device Technology: Home is Where the Heart Monitor Is,4 the list includes such things as a toothbrush that can sense, evaluate and monitor the bacteria present in your mouth, diagnose an infection, and maybe even determine not only when but which antibiotic is needed. Other products that Lewis says already are on the drawing board:
- Computer glasses that can help a person remember things and people through a tiny in-front-of-the-eye display;
- Skin mapping that can monitor a person who is prone to develop melanoma; and
- A smart bandage that can tell if a wound has gotten infected.
All of this will introduce new challenges regarding privacy, security, and the meaning of the concept of “personal space” — issues that are well beyond the scope of these discussions. But they will happen and they are happening, and what may currently be still thought of as science fiction may be available to you in the not-too-distant future as something that is intended not to take your place or do something for you to make your life easier, but to make your life better by helping to keep you healthier and more active. DM will embrace these technologies and incorporate them into the day-to-day activities of a program and a patient. The current and ongoing blending of DM with wellness and other less traditional spaces will likely accelerate some of this.
Some of this technology, in the form of hardware, already exists. Some will need to be developed, and all will continue to be refined, improved and miniaturized, and made faster and less expensive. But the factor that ultimately determines when these tools will become available and commonplace is likely not the hardware but the software. Creating the various sensors and devices to measure a whole variety of parameters is much further ahead than creating the systems needed to take all of that data in; analyze it; find the right patterns within it to show or predict problems; and then make the output concise and usable in a form that provides information to a patient or health care provider that can be acted upon.
Some of this is technical and has to do with systems, processors, and software capable of integrating ever-larger amounts and types of data. But a lot of it is also clinical and will require a very deep understanding of human disease and human behavior so that those who will create these complex algorithms and other means of pattern recognition and predictive modeling will not only ultimately know how to put such a wondrous computation together, but, perhaps more importantly, will know what questions to ask in the first place.
It will eventually be this ability to pick out that one important piece of information from the morass of data that will be the key to allowing the use of that information to determine how someone is doing and whether they are in need of further intervention; what may help them do better than they already are doing; or what may prevent them from getting worse over time.
We already have some of the capabilities of collecting some of these data but we do not even know how often some of the data ought to be collected, let alone what particular pattern(s) may provide that early identification of a problem that could not only prevent a hospitalization or ER visit but maybe even the complication or the disease itself. Physicians are never going to have the time to spend going through volumes and volumes of data, so it is likely going to be up to the computers themselves to not only collect the data, but to integrate, correlate, and analyze it to find the things that the DM nurse or the physician needs to know about and act upon.
These series of devices/computers will talk to one another and learn from one another through what has been called by the Institute of Electrical and Electronics Engineers (IEEE) “proactive computing,”1,2 where computers will be able to “sense, calculate, and act on behalf of a person with or without human interaction, as best fits the circumstances.” As the commoditization of these powerful sensors and processors continues, proactive computing will evolve “where computers anticipate the needs of people around them,”1,2 allowing the propagation and interaction with networks of sensors that infuse the patient’s milieu, including home and work and anywhere they may go.
In an article entitled “Remote Medical Monitoring” in the April 2008 issue of IEEE’s Computer magazine, the authors predict that “telemedicine (the delivery of primary care in situ, wherever the patient may be, via information and communications technologies, or ICT) will be revolutionized by the decreasing cost and increasing power of the ICT that are becoming ubiquitous in our lives.” They also point out, correctly, that the potential implications of that on public health are staggering.5
The DM company and call center of the future will be one of the hubs where this information is collected, collated, analyzed, stored, and then acted upon by the routing of that information to the place that will allow the best and the most appropriate interaction.
In that world of the future, that routing may be to the patient’s physician; to the patients themselves; to a caregiver; to a DM nurse or health educator; or, perhaps increasingly, back to the patient’s series of computers and sensors themselves to modify their interaction with the patient and help that patient achieve optimal health. We may or may not end up with the autodiagnostic full-body scanners seen in many science fiction movies or the handheld tricorder (medical hand-held multi-scanner) that Dr. McCoy from the original Star Trek series pioneered. But what we do end up with will likely eventually provide much the same level of information.
- A terabyte, a measure of computer storage capacity, is 2 to the 40th power, or approximately a thousand billion bytes (that is, a thousand gigabytes). Source: WhatIs.com. In most computer systems, a byte is a unit of data that is eight binary digits long. A byte is the unit most computers use to represent a character such as a letter, number, or typographic symbol (such as “g,” “5” or “?”). A byte can also hold a string of bits that need to be used in some larger unit for application purposes (for example, the stream of bits that constitute a visual image for a program that displays images or the string of bits that constitutes the machine code of a computer program). Source: SearchStorage.com.
- Remote Control for Health Care by Barnaby J. Feder; Published Sept. 10, 2006; The New York Times (business section).
- DARPA is part of the U.S. Department of Defense. The wearable system called the “smart T-shirt” has already been used successfully to monitor the vital signs of climbers on an expedition to Mount Everest.
- “Emerging Trends in Medical Device Technology: Home is Where the Heart Monitor Is,” Carol Lewis; FDA Consumer magazine, May-June 2001.
- “Remote Medical Monitoring” Jurik, A.D.; Weaver, A.C.; IEEE Computer magazine; Volume 41, Issue 4, April 2008 Page(s): 96-99.
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It is the ability of smart devices to do their work without being obvious and without interfering with the day-to-day activities of people that will allow their widespread usage and acceptance.
Physicians are never going to have the time to spend going through volumes and volumes of data, so it is going to be up to the computers themselves to integrate, correlate, and analyze.