Oral Health Group
Feature

Viewpoint: The Creative Destruction of Medical Histories

February 3, 2016
by Dr. Peter Nkansah, DDS, Dip. Anaes.


The term “creative destruction” was coined by Joseph Schumpeter in 1942.1 Schumpeter was an economist who was commenting on how capitalism evolves. Creative destruction in its original form refers to industrial mutations that revolutionize economic structures from within, creating a new structure. Put another way, it is the free market’s way of delivering progress.2 This term for system restructuring was recently co-opted by Dr. Eric Topol for his book, The Creative Destruction of Medicine. The thrust of the book was that the worlds of technology and healthcare (specifically medicine in the United States) were on an inevitable collision course. The ultimate benefactor would be the patient, which means everyone, sooner or later. His follow-up book, The Patient Will See You Now, published in 2015 further pushed this point and made a convincing argument that this reform would change the drivers of healthcare and (later) benefit both the doctor and the patient. Many of the advances would be made via patients/people themselves through their smartphones. Keep in mind that the number of smartphones in the world rivals the number of people in the world, and that connected devices comfortably outnumber Earth’s human population.3,4 The focus of this article will be to examine how this collision might influence how we assess our patients’ health status.

Not that long ago, medical histories were pretty much made up of the Big Six questions (i.e. adverse reactions to medications, drug allergies, heart murmurs, recent hospitalizations, medications, history of rheumatic fever). Maybe we would take a blood pressure reading, or (more often) maybe not. Dental offices were on the second floor of walk-up buildings so that the sicker patients couldn’t reach you, so much of the medical screening took care of itself. But times have changed; medical histories and history-taking have significantly evolved. Even the most basic of medical history questionnaires now are a full page long. However, they still tend to ask for “snapshot” data points. That is, they report on information that is collected maybe once a year during an annual visit to the family physician. Data collection methods are changing, with many physical measures now obtainable at home. This also means that information can be collected longitudinally and that trends and events can be marked and communicated faithfully.

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Dentistry has embraced technology for a long time (e.g. CEREC®, The Wand®) and will continue to do so. The new players in the health data collection game are non-dental and almost ubiquitous; they are smartphones, other smart devices (like the weigh scale that measures your heart rate and analyzes body composition) and tablets. These devices and their corresponding apps, which as of July 2015 numbered 1.6 million for Google, 1.5 million for Apple, 400,000 for Amazon, 340,000 for Windows, and 130,000 for BlackBerry, can do amazing things already and we are only in the early phases.5 It hardly seems possible that the first iPhone was introduced in 2007, but you can Google it to verify that fact. We can now carry around considerably more computing power than was used to get man to the moon. More tasks and measurements are coming, many of them previously unthinkable except in Star Trek (e.g. ultrasound, microscopy, radiographs).

Whether you embrace technology or not may not be the point. This is because you aren’t in the equation. Your patients can independently decide to employ these technologies. Many of them either already have taken some of these steps, or are about to. And medicine will be forced to adopt these changes because of patient demands and because of the never-ending search to save dollars for our financially-strapped healthcare system. This may mean that the biggest change to the medical assessment of your patients will be your use (or non-use) of medical consultations. These technologies will eliminate the need for some of the consultations, and when they are needed, the results will be quicker to arrive and will contain more information than before.

The following represents a quick look into some apps and device add-ons for smartphones that turn them into medical devices that you and/or your patients can own. Without intentional bias to one device/company/brand or another, here are some specific examples of medical devices that your patients can afford and can own today:

• The Withings™ Wireless Blood Pressure Monitor is an example of a validated automated blood pressure monitoring system. This device links directly with the Health Mate™ app, which provides a chart for one’s blood pressure readings as a timeline or a dashboard. It has been approved for medical use in Canada, the United States, Australia, and New Zealand. It also satisfies the medical device regulations in Europe. It could be used in your office, but more likely, someone who has hypertension or some other blood pressure issue would use it to monitor themselves. They could share their data with you electronically with a tap on their phone. These data could track trends over the days, weeks or months. At a listed price of $129.95 (US), it is an attractive, accurate device.6

• Eko Devices, Inc. recently received approval from the Federal Drug Administration (FDA) in the United States for its Eko Core digital stethoscope.7 Now, the stethoscope has not changed much over its 200-year history, and it is not a stretch to suggest that most dentists are not comfortable or competent in using them. That is true even for our medical colleagues. A January 2, 2016 article by Lenny Bernstein in The Washington Post referenced 3 studies where auscultation skills were disappointing.8 A digital stethoscope is actually an attachment for a standard stethoscope that amplifies the sounds and communicates them wirelessly to an iPhone. From there, a faithful reproduction can be transmitted and analyzed by a cardiologist in another location or the sounds can be analysed by an electronic algorithm for a differential diagnosis. The data from the Eko Core can be compiled in the Eko Stethoscope app that accompanies your $199 (US) purchase or collated into the drchrono electronic health record platform.9

• The AliveCor® Mobile ECG ($74.99 US) and its associated AliveECG app can capture electrocardiogram tracings and measure heart rate at any time.10,11 This technology is currently most suited to patients with atrial fibrillation. Within this technology, there is an FDA-approved “normal detector”, so that patients (or you) can know when further actions may be advisable. Tracings can be stored in a patient’s own dashboard or automatically uploaded to the web-based Practice Fusion EHR. There is also the option of manually uploaded a PDF file to you or any other interested party.10 Any particular tracing can also be sent for expert immediate review by a cardiologist, cardiac technician or (in the UK and Ireland) cardiac physiologist. This immediate service is provided for a fee. A trial is currently underway to test its 12-lead ECG capability as well as testing an algorithm to diagnose ST-elevation myocardial infarctions, which require prompt percutaneous cardiac intervention (i.e. angioplasty).12

• Frequent blood glucose measurements are a fact of life for patients with diabetes mellitus. The range of disorders that we group as diabetes mellitus is a fact of life for almost 10% of Canadians, according to the Canadian Diabetes Association.13 Abbott Diabetes Care has released the FreeStyle Libre Flash that can collect blood glucose readings via a wearable sensor that attaches to the arm; there is no needlestick, as the reading comes from interstitial fluid.14 In this system, there is a water-resistant sensor that attaches to the skin, then the measuring device is held within 1 to 4 cm away for one second in order to get a blood glucose reading. The results are transmitted to a smartphone or other mobile device and trends are noted. Currently, this device is not available in North America, but that is being actively addressed. The cost in Europe for the touchscreen reader and a 14-day wearable sensor is €59.90. Perhaps even more exciting is the A1C Now+® Analyser from Roxon medi-tech ltd. The gold-standard parameter to assess blood glucose control over time is the haemoglobin A1c measure. This has always been the domain of physicians and blood labs, therefore requiring days if not weeks for dentists to get results. Using a 5 µL blood sample (a needlestick volume), the HbA1c reading can be obtained in five minutes.15

• Obstructive sleep apnea (OSA) provides a clear and present health concern to our patients. It is strongly associated with cardiovascular disease, diabetes mellitus, and liver dysfunction. It has all kinds of implications for sedation dentistry too. It is also something that we, as dentists, can have a role in treating. Currently, polysomnography and oximetry (a sleep lab test) comprise the gold-standard method of testing for and measuring the severity of OSA. These tests take place in a sleep lab, which in part leads to a high number of undiagnosed sufferers. Recently, two apps have simultaneously been developed to help screen patients for OSA at home. ApneaApp was developed at the University of Washington; it uses a smartphone as kind of a sonar to “watch” how patients sleep. The SmartCare Sleep app was developed at Oxford University. After gathering some patient data (e.g. age, weight), it uses the phone’s accelerometer and microphone to monitor the sleep. It can also integrate data from other wireless devices, like pulse oximeters.16 In both cases, algorithms are used to predict the likelihood of OSA; polysomnography can follow. Accuracy results have exceeded 90%.

If, after all of this, you have decided to start your own health-tracking file and have a concern about how to put all of your data from these varied devices together, there are some apps for that too. HealthKit (Apple), 2Net™ (Qualcomm) and Solution (Validic) are examples of personal digital health platforms. Each of these collect data from the various sources and insert them into a cloud-based file. Validic’s VitalSnap™ is the newest wrinkle to this process. VitalSnap™ is billed as the first mobile health technology to allow for the transfer of data from non-connected devices to health IT systems. Simply put, you use your smartphone to take a “picture” of the measuring device’s displayed result. The data from the device is recognized, digitized, and delivered to your health record, patient portal or platform dashboard.17

Dental/medical consultations are changing. Indeed, dentistry and medicine are experiencing creative destruction. While the term sounds bad, it is a term marking progress, however messy it may be. This brief article has only scratched the surface of some of the changes coming our way in the immediate future. Once the not-insignificant security issues are worked out, these changes will present the rare situation where potentially everyone can benefit.OH


 

Dr. Nkansah is a Dental Anaesthetist with a private practice in Toronto. He is a member of the editorial board for Oral Health and is an Assistant Professor at the University of Toronto’s Faculty of Dentistry.

References:
1. Topol E. The Patient Will See You Now. New York: Basic Books; 2015.

2. Cox WM and Alm R. “Creative Destruction.” The Concise Encyclopedia of Economics. 2008. Library of Economics and Liberty. Retrieved January 1, 2016 from the World Wide Web: http://www.econlib.org/library/Enc/CreativeDestruction.html

3. Lunden I. “6.1B Smartphone Users Globally By 2020, Overtaking Basic Fixed Phone Subscriptions” TechCrunch. TechCrunch, 2 June 2015. Retrieved January 3, 2016 from the World Wide Web: http://techcrunch.com/2015/06/02/6-1b-smartphone-users-globally-by-2020-overtaking-basic-fixed-phone-subscriptions/#.boxzif8:RPIH

4. “Smartphones – Statistics and Facts”. Statista. Statista, 7 December 2015. Retrieved January 3, 2016 from the World Wide Web: http://www.statista.com/topics/840/smartphones/

5. “Number of apps available in leading app stores as of July 2015”. Statista. Statista, January 2016. Retrieved January 8, 2016 from the World Wide Web: http://www.statista.com/statistics/276623/number-of-apps-available-in-leading-app-stores/

6. Withings Inc. Retrieved January 8, 2016 from the World Wide Web: https://www.withings.com/us/en/products/blood-pressure-monitor

7. Eko Devices. Retrieved January 8, 2016 from the World Wide Web: https://ekodevices.com/how_it_works

8. Bernstein, L. Heart doctors are listening for clues to the future of their stethoscopes. The Washington Post [Internet]. 2016 January 2. Retrieved from the World Wide Web: https://www.washingtonpost.com/national/health-science/heart-doctors-are-listening-for-clues-to-the-future-of-their-stethoscopes/2016/01/02/bd73b000-a98d-11e5-8058-480b572b4aae_story.html

9. drchrono Inc. Retrieved January 8, 2016 from the World Wide Web: https://www.drchrono.com/

10. AliveCor, Inc. Retrieved January 8, 2016 from the World Wide Web: http://www.alivecor.com/home

11. Misra, S. AliveCor ECG is approved for over the counter sales. iMedicalApps. iMedicalApps, 11 February 2014. Retrieved January 8, 2016 from the World Wide Web: http://www.imedicalapps.com/2014/02/alivecor-ecg-approved-counter-sales/

12. Misra, S. AliveCor Heart Monitor clinical trial to test ability to capture 12-lead ECG, diagnose heart attack. iMedicalApps. iMedicalApps, 23 July 2015. Retrieved January 8, 2016 from the World Wide Web: http://www.imedicalapps.com/2015/07/alivecor-heart-attack-study/

13. Canadian Dental Association and Diabetes Québec. Diabetes: Canada at the Tipping Point. 2010. Retrieved January 9, 2016 from the World Wide Web: https://www.diabetes.ca/CDA/media/documents/publications-and-newsletters/advocacy-reports/canada-at-the-tipping-point-english.pdf

14. Cerrato P. Painless way for diabetes patients to measure Blood Glucose. iMedicalApps. iMedicalApps, 23 November 2015. Retrieved January 9, 2016 from the World Wide Web: http://www.imedicalapps.com/2015/11/painless-diabetes-patients-blood-glucose/

15. Roxon medi-tech ltd. Retrieved January 9, 2016 from the World Wide Web: http://www.roxon.ca/site/product/386

16. Algaze B. Diagnosing sleep apnea with smartphone apps. Extremetech. Extremetech, 30 April 2015. Retrieved November 30, 2015: http://www.extremetech.com/extreme/204606-diagnosing-sleep-apnea-with-smartphone-apps

17. Misra S. VitalSnap lets patients connect their unconnected devices by just taking a picture. iMedicalApps. iMedicalApps, 8 January 2016. Retrieved January 10, 2016 from the World Wide Web: http://www.imedicalapps.com/2016/01/vitalsnap-lets-patients-connect-their-unconnected-devices-by-just-taking-a-picture


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