Patients as Medical Apps

I was reading yesterday about a new device from HP that is built upon the latest technology from Microsoft. I am by no means the first person to say this, but Microsoft has definitely graduated to a company that understands the value of user interface and design. Despite all the difficulties with interim versions of Windows [Windows ME, Vista, Windows 8], the present version of Windows 10 seems to have achieved success on multiple fronts.

First of all, despite the inevitable major bug squashing period which will likely last a few more months, Windows 10 is a tremendous feat of engineering. Having a single installed base for every type of device has clear benefits. More so, the fact that Microsoft has decided to stop selling incremental installs of Windows as separate products, and instead is adopting a continuous update approach, speaks to the new type of world we are living in – a world where nothing is finished, but is constantly being adjusted and customized to the needs of the user.

The specific HP product I am referring to, uses a new capability associated with Windows 10, which works on appropriately powered Windows phones. It has also been said many times before that we are at a stage where the supercomputer in our pockets is not rarely more powerful than the lumbering desktop with its wires and network cabling. Microsoft has built an ecosystem around this concept, whereby the mobile device [which in this case is bordering on a phablet] plugs into a docking station, which is then connected to a full screen, keyboard and mouse. The same mobile device can also be placed next to a laptop shell and take command of the screen and keyboard/mouse.

Effectively, one is taking the CPU and memory and other functionalities of the internals of the mobile device and plugging them into various different shells. If it is your intent to be working on your phone, at the same time that you are Skyping on your laptop, and running a major video conversion on your desktop,  this is not for you. But if you are like many business people, who find themselves wasting a tremendous amount of time just synchronizing their work environment between locations, this is a dream.

You are effectively carrying your entire work environment with you at all times and you can access that environment in any way that you wish, via any interface that you wish. There is no inherent reason why there could not be a docking station that connects to a unique gaming hardware setup. The same mobile device could drive a whole range of wearables that are once again, just empty shells dependent on the “brains” contained within the mobile device. This entire technology is referred to as “Continuum”, and is physically and conceptually beautiful. And yes, I would go so far as to say that this is the kind of thing that I would have expected from Apple.

A few years from now, the computing capability of mobile phones will be exponentially greater than it is now, and the internals of the phones will be far smaller. Despite people’s aversions to the thought of being implanted with a chip, the day will come when a fingernail sized device will wirelessly drive  a whole range of shells. The scenario I described above, whereby an individual would want to be using their phone, laptop and desktop all simultaneously, will not be a problem for super-multicore systems that are either just under our skin, or in a wristband that is worn at all times.

Our entire environment, or if you wish, our digital avatars, will reside in the cloud so that damage to the chip will require nothing more than a quick replacement of the hardware. Multiple biometric signals will identify us to the newly replaced chip, and our entire work environment will be reestablished and available to us in any physical or virtual format that we wish. And I would be surprised if this technology is not in place by 2030. This is by no means wild thinking or science fiction. We are already almost there, and once we are there, we will find it hard to believe how we ever managed beforehand.

Now that I have raved on about this new type of technology, and its specific manifestation via HP, I want to refer to a review that called all of this “too little, too late”. The reviewer loved the concept and barring a few quibbles, thought that the implementation was excellent. The problem, as the reviewer stated, is that the Microsoft ecosystem built around Windows 10, has a very weak app store.

Once upon a time, people bought computers and then bought software on floppy devices which progressed to hard cylindrical discs which alternated with various types of external media [does anyone remember the Zip drives]. At a certain point, Microsoft office was the de facto standard for word processing and spreadsheet work. At a certain point, after the sad death of Harvard graphics, PowerPoint became the standard for making presentations. When projectors became cheap enough to be available in every boardroom and public hall, physical slides  were no longer generated from presentation programs. People would be updating their slides until the last second and then immediately display them to a large audience.

Microsoft truly had a hold on this entire market, and still has a very strong hold on this entire market. I am, nevertheless, one of the many people who has made the move to Google’s online environment, and feel no sentimentality over no longer using Microsoft productivity tools. Despite my fellow Googlers, Microsoft is by no means out of the game. Microsoft has a very strong online presence, and in the business world, has a very powerful and extensive suite of server capabilities that plug into the online versions of their software. The sum total of all of this is that the physical media that was, not that long ago, foundational to the implementation and use of productivity software, has now all been virtualized.

The next step in this process was the “app”lification of functionality. Today, with people using their phones on a near constant basis, functionality is something that you download from a specialized location, a “store”, and which is often free, or at the very least, is inexpensive [a few dollars or even less]. Some functionality works purely on a subscription basis. I personally subscribe to  five different online services, each of which cost me less than $10 a month.

While $120 a year, and $360 over three years, is a lot of money, the subscription approach is an amazingly effective marketing tool for lessening the pain. I simply would not pay $360 every three years for the next upgraded version  of just one of the software utilities I regularly use. But paying $10 a month, and knowing that I am getting constant updates, makes it sound like a great deal. It is all automated, updated both on my phone and desktop, available via any browser, and simply put, answers my needs.

This re-conceptualising of software is because of the iPhone, which is yet another reason the iPhone is a landmark device. Apple has, by far, the largest collection of these units of functionality, i.e. apps, and it is this store of such units of capability that still drives people to prefer Apple phones, even when there are excellent and far cheaper Android alternatives. The Android App Store is also very complete, and I personally have not come across a situation where the Android App Store did not offer me the app that I was looking for.

Now, let’s talk about Windows. The Windows App Store is by far the weakest. There are certain services that are considered essential by many users, that do not appear in a Windows version. If an app I needed did not have a Windows 10 version, I would not buy a Windows mobile phone, even if it was superior in every other way to my present Android phone.

So, we have become a society that thinks about computers, and perhaps life as a whole, not as a single unit but as a collection of pieces of functionality. I will now finally address the title of this blog post, which occurred to me, once again, while reading in my home library. I am pretty much convinced that this is the direction that medical software must take.

At present, the leading electronic medical record (EMR) solutions are all based on a decades-old model of software design. Basically, you develop a program that grows to be a mammoth piece of software that incorporates, over time and growing client base, more and more functionality as needed. Eventually, there is no choice but to create layers and layers of tabs and menus to offer access to all of this functionality.

When doing morning rounds to evaluate the health and status of every patient, it is necessary to navigate a maze of EMR interfaces, even if all you want to do is check a blood pressure and order a medication. It would be the equivalent of having to go downstairs and get into a Ferrari anytime you wanted to go even the smallest distance. It’s slow, it’s overkill, it’s complicated, and there has to be a better way.

Now imagine that each patient is assigned his or her own app at the time of admission. One could refer to this as their own avatar. This avatar would be based on a standardized envelope of functionality that handles all the messy work of talking to the hospital EMR, interacting with the patient’s wearables, talking to social media as needed, and more. In time, and this by no means demands a dramatic new level of computer capability, the avatar could appear on a screen next to the patient’s bed or on a wristband that the patient is wearing.

The medical staff would speak both to the patient and the avatar. The avatar would focus on the medical concerns specific to the patient. So for diabetic patients, the avatar would know that it is important to display the last series of blood sugar levels, which would not be necessary in the young patient who just underwent the removal of his or her appendix.

Now, what if the patient develops a clot in the leg. Well, the doctor could then, by voice command or some other interface, add an app to the avatar that is specifically related to dealing with leg clots. Suddenly the avatar begins to collect information about leg clots, presents it to the doctor and possibly even recommends changes in medications, or provides special nursing advice for patient mobilization, and so on.

What if the patient develops heart failure? Same thing. You add an app related to heart failure, to the avatar. Suddenly, changes are made in dietary recommendations, and the nurse receives a request to make sure that the patient’s head is kept up at a 30 degree angle. If this same patient does not have diabetes, why even have a menu option for displaying serial blood glucose measurements? 

Of course, in the background, you could have software that is constantly monitoring the patient to identify unexpected complications. Perhaps the patient develops diabetes during the hospital stay and this is detected by random blood samples. The EMR of the hospital would speak to the avatar and they would decide how to manage this, and when to involve the medical staff. The avatar might end up suggesting the addition of the diabetes app.

This avatar would not exist only in the hospital system. It would be universally available, with all proper securities, in the cloud. So when the patient walks into an urgent care clinic in a community, the avatar would be there to summarize the patient’s health status, and warn the staff about the patient’s tendency to fainting. If the same patient collapses on the street, the avatar would be there when the paramedics arrive, to once again summarize the patient’s health status and possibly even make recommendations for management.

In summary, one of the reasons why EMRs have grown out of control, and have become behemoths that so intimidate physicians, is that our medical knowledge continues to grow. Also,  our medical responsibility continues to grow. It is not acceptable that a patient should have a significant bleed internally, after surgery, and not have this be picked up in some way [such as a moderate but continuous increase in baseline pulse rate]. If the patient avatar had a post-op app added to it, this is one of the things that it would look for.

What would it take to start from a blank screen, and build such a system? We live in a world where the term “billion” no longer seems to have much significance. Implementations of multi-hospital EMRs cost in the hundreds of millions to over a billion dollars. Let’s say that it would cost hundreds of millions to a billion dollars to create this avatar/app approach to managing patient care. Companies would compete to write apps that serve the needs of the patients and doctors. Individuals and institutions would pay for the use of these apps. And because one is only using the apps necessary for a given patient, the cost per patient would be less than it is now.

I would consider such a project to be on the “moon shot” scale. It requires a complete retooling of the software that all medical and health services provide. At the same time, I truly believe that this is the only way to compartmentalize the complexity of patient health. Given the statistics on doctor satisfaction with EMRs, and the costs involved with implementing and using these EMRs, I definitely believe that a drastic alternative is necessary. And I ask that you consider what I have just suggested as that alternative.

Thanks for listening

About the Author
Dr. Nahum Kovalski received his bachelor's of science in computer science and his medical degree in Canada. He came to Israel in 1991 and married his wife of 22 years in 1992. He has 3 amazing children and has lived in Jerusalem since making Aliyah. Dr. Kovalski was with TEREM Emergency Medical Services for 21 years until June of 2014, and is now a private consultant on medicine and technology.
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