Steven Steinhubl, MD Director of Digital Medicine Scripps Translational Science Institute Clinical Cardiologist Scripps Health Read his full interview - http://bit.ly/1fg5rFz View photos from the show - iHT² Health IT Summit San Diego - “Medicine Unplugged: Bringing the Solution to the Problem through Mobile Medicine” with Steven Steinhubl, MD, Director of Digital Medicine, Scripps Translational Science Institute, Clinical Cardiologist, Scripps Health Extraordinary advancements in mobile technology and connectivity over the last several decades have provided the foundation needed to dramatically change the way healthcare is currently practiced. While the utilization of mobile telecommunication technologies for the delivery of healthcare (mobile health, or mHealth), is still in its earliest stages of development, the evidence supporting its potential to impact the delivery of care, to improve outcomes and lower costs is apparent. For healthcare consumers, mHealth technologies can allow for the more convenient, rapid and personalized diagnosis of some of the most common acute symptomatic illnesses. In individuals with chronic medical conditions, who account for nearly 90% of healthcare spending, mHealth technologies can transform their care through improved monitoring, tracking, and engagement of critical biometrics during routine daily activities, not only in doctor’s offices. In addition, despite greatly empowering patients to better care for themselves, this transformation in care will actually reinforce the doctor-patient relationship by allowing physicians to re-establish their role as diagnostician and educator for their patients. mHealth technologies have the potential to radically change every aspect of the healthcare environment but clinical trial evidence of its overall benefit to the patient and the healthcare system are still needed. Learning Objectives: ∙ Be able to incorporate mobile health technologies into current practice. ∙ Explain to patients and colleagues the current gaps in care that can be better managed with mobile technologies ∙ List 4 devices under development that may contribute to the re-engineering of healthcare in the future.

1. Medicine Unplugged: Bringing the Solution to
the Problem through Mobile Health
January 22, 2014
Steve Steinhubl, MD

2. Improvements in Healthcare Over Time 
80% Decline in CV Death Rates
Thompson D. Atlantic Monthly March 19, 2012

3. But at a Cost….
Thompson D. Atlantic Monthly March 19, 2012

4. Healthcare Today: Primarily Sickness Care that
Requires Traveling to the Solution
Sources of
Solutions:
Hospital
Physician
ED
Doctor’s Office
Patient

5. Can mobile health (mHealth)
technologies transform
healthcare by bringing the
solution to the consumer, and in
so doing, improve satisfaction
and decrease costs?

6. Medicine Unplugged:
Bringing Solutions
Problem
1. Wellness
₋ Activity & Weight Loss
- Stress Management
₋ Sleep Optimization
- Cancer Prevention
2. Acute Disease Diagnostics
₋ Common Infections
3. Chronic Disease Management
₋ Hypertension
4. Medication Adherence
- Diabetes

7. Medicine Unplugged:
Bringing Solutions
Problem
1. Wellness
₋ Activity & Weight Loss
- Stress Management
₋ Sleep Optimization
- Cancer Prevention
2. Acute Disease Diagnostics
₋ Common Infections
3. Chronic Disease Management
₋ Hypertension
4. Medication Adherence
- Diabetes

8. How “Well” are We Relative to Other
Countries? Obesity Rates
% Obese Adults
http://www.oecd-ilibrary.org/sites/health_glance-2011-en/00/02/index.html

9. Walking and Cycling Rates Worldwide
Bassett DR. J Physical Activity Health 2008;5:795-814

10. Life Expectancy Relative to Health
Care Expenditure per Capita
Thompson D. Atlantic Monthly March 19, 2012

11. How Well Does the Current Healthcare System
Perform in Meeting Consumers Wellness Needs?
• 83 million adults spend $33.9 billion annually,
mostly out-of-pocket, on complimentary or
alternative medicine.
• In addition we spend another $11 billion out-ofpocket for vitamins and mineral supplements.
• It is estimated that ~108 million Americans dieters
spent ~$66 billion in 2013, almost all out-of-pocket,
on weight loss programs.
$111 billion annual out-of-pocket wellness care ≈ Total fast food sales 2013
NCCAM July 2009: http://nccam.nih.gov/news/camstats/costs/costdatafs.htm.
MarketData Enterprises. U.S. Weight Loss & Diet Control Market (12th edition). April 2013

12. The DNA of Hunter-Gatherers: Immobility
Leads to a Stress Response
•
Our hunter-gatherer relatives are thought to have travelled
on average ~20 km per day.
•
When we achieve 30 minutes of brisk walking everyday
(which < half of US citizens do) that corresponds to only
~2.5km per day.
Charansonney OL. Nature Rev Card 2010;7:468-72

13. Dose-Response Relationship to
Increasing Physical Activity
416,175 individuals with ~8 years of follow-up. On the basis of the amount of self
reported weekly exercise association between activity and mortality was
determined
Individuals considered in the low
volume activity group exercised at
a moderate level (brisk walking)
for an average of 92 min/wk (~15
min/day) had a 14% reduced risk
of all-cause mortality and had a 3
year longer life expectancy
compared to inactive participants.
Every additional 15 min of daily
exercise beyond 15 min a day
further reduced all-cause mortality
by 4%
Wen CP. Lancet 2011;378:1244-1253

14. Screen-Based Entertainment
Time and Mortality
• TV watching is second only to sleep as the behavior that occupies
the most time at home.
• Observational study of ~4,500 had screen time assessed and 4
years follow-up.
HR AllCause
Mortality
<2hr/day
2-4 hr/day
>4 hr/day
Stamatakis E. J Am Coll Card 2011;57:292-9
1.00
1.13
1.77*
HR CV
Disease
1.00
2.20*
2.76*
* p<0.05

16. Does Tracking Activity Improve
Activity?
Systematic review of 26 studies (8 RCT, 18 observational, total of
2767 participants) studying the association between pedometer
use and physical activity.
Randomized Trials
 of 2491 steps
Bravata DM. JAMA 2007;298:2296-3204

17. Change in Daily Ambulation and CV Events in
People with Impaired Glucose Tolerance
9306 individuals with IGT followed up for an average of 6 years. Ambulatory
activity was assessed at baseline and 12 months.
Both baseline activity and
change in activity were
independently and inversely
associated with a decrease in
CV events with an ~ 10%
relative reduction per 2000
steps per day.
Yates T. Lancet - Online Dec 20, 2013

18. Accelerometers and Digital Coaching to
Improve Activity
235 inactive adults, age 60-70. Randomized to a 3 month intervention with
(1) an accelerometer-based activity monitor, (2) a personal website, and (3)
a personal e-coach, who provided regular updates of the individual’s
physical activity status by email and gives advice to increase physical
activities, or control.
Wijsman CA. J Med Internet Res. 2013;15:e233

19. Need Help Losing Weight?
Just Exhale
We each have individual breath phenotypes.
The overall breath-mass spectrum to breath-donor
recognition score was 76% over 193 samples.
10 October 2012
Martinez-Lozano Sinues P. PLoS One 2013 8(4): e59909.

20. Breath Analysis can Potentially Aid Dieters by
Providing Real-Time Fat-Burning Information
Samudrala D. Obesity 2014 Jan 11. doi: 10.1002/oby.20696

21. “Insufficient Sleep Is a Public Health
Epidemic” - CDC Jan 2014
• About 70 million Americans suffer from chronic sleep
problems.
• 18 million ,~5% adult population, suffer from sleep apnea.
• Sleep problems are critically under-addressed contributors
to a number of chronic diseases and conditions, including
diabetes, cardiovascular disease, obesity, and depression
http://www.cdc.gov/sleep/about_us.htm

22. Diagnosing Sleep Disorders - Today
• Over the last 10 years the number of accredited sleep labs has
quadrupled.
• Each night in a sleep lab is ~$1,900 (mostly covered by insurance)
• Medicare payments alone for sleep testing were $235 million in 2009
Kaiser Health News Jan 2012

23. The Future of Diagnosing Sleep
Disorders
• Actigraphy is the continuous recording of body (often wrist)
movement.
• Allows for sleep-wake information to be gathered, but not sleep
stages.
• In head-to-head testing against polysomnographic predictive value for
sleep was 87%.
Pollak CP. SLEEP 2001;24:957-65

24. Ballistocardiography Systems for Enhanced
Monitoring and Improving Sleep
• Under mattress sensor that monitors
movement, heart rate and breathing .
• Monitors room environment (temp, noise).
• Sleep stage awakening.
http://www.beddit.com/ and http://www.withings.com/en/aura

25. Depression & Anxiety
• Depression affects 9.1%
of the US population at
any one time.
• Major depressive
disorder is the leading
cause of disability in US
for ages 15 to 45.
• Only 50% of individuals
with major depression
receive treatment.
• Anxiety disorders are
most common mental
illness in US affecting 40
million.
• Total annual cost related
to anxiety ~ $42 billion.
http://www.cdc.gov/features/dsdepression/ and http://www.nimh.nih.gov/

26. Triggers of Anxiety/Depression are Different
in Everyone, and Often Subconscious
Objective measures of autonomic nervous system activity can help
individuals recognize stress triggers and what helps minimize them.
Electrodermal Activity
(EDA) is a sensitive
measure of
sympathetic nervous
system activity
Heart rate variability (HRV)
varies based on autonomic
nervous system activity. The
less stress, the greater
parasympathetic activity, the
greater the variability.

27. mHeath Tools for Checking and
Tracking HRV

28. mHealth Tools for Checking and
Tracking EDA
http://www.cs.rochester.edu/hci/pubs/pdfs/FoodMood.pdf

29. Other Methods of Stress / Mood
Tracking
Clmtrackr: Face
tracking technology
to track mood
StressSense: Algorithm
analyses the tonal
expression of the human
voice to help people track
and monitor their moods
MyBreath: Records 1-3
minutes of breathing and
then measures, analyzes
and trains your breathing.
http://pac.cs.cornell.edu/pubs/ubicomp2012_StressSense.pdf

30. Cancer Detection Guidelines –
American Cancer Society
• Yearly mammograms are recommended starting at age 40
and continuing for as long as a woman is in good health.
 In 2011 only 53.6% of women reported having a
mammogram in the last year.
• Beginning at age 50, both men and women should have a
flexible sigmoidoscopy every 5 years, or colonoscopy
every 10.
 ~50% of the US population receive recommended
colon cancer screening tests.
• For high risk individuals age 55-74 low-dose CT scan
screening is recommended.
Pace LE. Cancer 2013;119:2518–2523
Hudson SV. J Am Board Fam Med 2012;25:782-791

31. Passive or Active Screening of Multiple
Cancers Through Breath Analysis
Lung, breast, colon and others have been studied.
Peng G. Nature Nanotechnology 2009;4:669-73

32. Mhealth Tools for Simplified
Population Screening for Cancer
Two billion women
worldwide are un-screened
for cervical cancer
Simple attachment to
a mobile phone turns
it into a multimodal
imaging device for
screening for cervical
cancer.
http://www.mobileoct.com/
Oral cavity cancer is amongst the
most prevalent cancers worldwide

33. Consumer / Provider Platforms to
Empower and Engage (e.g. Tictrac)

34. Medicine Unplugged:
Bringing Solutions
Problem
1. Wellness
₋ Activity & Weight Loss
- Stress Management
₋ Sleep Optimization
- Cancer Prevention
2. Acute Disease Diagnostics
₋ Common Infections
3. Chronic Disease Management
₋ Hypertension
4. Medication Adherence
- Diabetes

35. Upper Respiratory Tract Infection (URI) –
Treating the Common Cold
1. Viral respiratory tract infections, “colds” are the
most common acute illness in humans and the
most common reason for an urgent office visit. 1
2. Adults average 2-4 colds annually.
3. The estimated total annual economic impact of
non-influenza viral URIs is ~$40 billion in the US
alone.2
4. There is no role for radiologic or lab studies in the
diagnosis or treatment of URIs.
1. Cooper RJ. Ann Intern Med. 2001, 134: 509-517
2. Fendrick A. Arch Intern Med 2003;163:487-94

36. Potential mHealth Solutions for the
Common Cold
• Thermometer that measures
temperature, and…
 Tracts symptoms
 Informs you of others in same
community (school, workplace)
with similar symptoms.
 Can send information to
provider’s office
• In the near future, POC tests
will allow for home diagnosis of
exact pathogen.1
1. Lodes MJ. PLoS One 2007; 2(9): e924.

37. Scanadu Scout

38. Urinary Tract Infections
1. Most common bacterial infections in adults. 1
2. Accounts for roughly 7 million office visits, 1
million ER visits and 100,000 hospitalizations
annually. 1
3. UTIs are responsible for an estimated cost of $2
billion dollar annually. 1
4. Only ~50% of women presenting with symptoms
concerning for UTI are actually diagnosed as
having one after evaluation.2
1. Foxman B. The American Journal of Medicine. 2002;113:5-13.
2. Bent S. JAMA. 2002;287(20):2701-2710.

39. mHealth Solutions for the Home Diagnosis
of UTI
• Several mobile devices are designed
for at-home urinalysis with analytic,
tracking and transmission capability.
• Future advances will likely allow for
the detection of both the presence
of infection and the exact pathogen
via a mobile electrochemical
biosensor .1
1. Mohan R. PLoS One 2011;6(10):e26846.

40. Otitis Media
1. Recurrent ear infection is the most common
acute complaint of children leading to ~30 million
pediatrician visits annually.1
2. Responsible for annual costs over $5 billion
dollars, not including lost work time by family
caregivers. 1
3. For every 100 children utilizing a healthcare
service because of their parent’s suspicion for an
acute ear infection, only 50 are actually
diagnosed to have an ear infections.2
1. Bondy J. Pediatrics 2000;105(6):e72.
2. Laine MK Pediatrics 2010;125(5):e1154-e1161.

41. Home Diagnosis of Otitis Media –
Smartphone Otoscope
• By giving parents the ability
to digitally image their
child’s tympanic membranes
at home with a smartphonebased otoscope a substantial
percentage of office visits
could potentially be
prevented with remote
image transmission and
diagnosis

42. Medicine Unplugged:
Bringing Solutions
Problem
1. Wellness
₋ Activity & Weight Loss
- Stress Management
₋ Sleep Optimization
- Cancer Prevention
2. Acute Disease Diagnostics
₋ Common Infections
3. Chronic Disease Management
₋ Hypertension
4. Medication Adherence
- Diabetes

43. Hypertension (HTN): Scope of the Problem
1. One of every 3 adults in America have HTN. 1
2. Nearly $100 billion in total costs are attributed to
HTN annually in the US. 2
3. Nearly 40 million office visits every year in the US
have a primary diagnosis of HTN making it the
single most common reason for an office visit.3
4. Less than half of all hypertensive individuals have
their blood pressure under control. 1
1. MMWR. Morbidity and mortality weekly report 2011;60(4):103-108.
2. Heidenreich PA. Circulation 2011;123(8):933-944.
3. National Ambulatory Medical Care Survey: 2010 Summary Tables.

44. Improving HTN Management Through
mHealth
• Home BP monitoring alone is
already known to improve BP
control, although only slightly.1
• When home monitoring is couple
with provider feedback and patient
engagement there is much greater
BP control than with monitoring
alone.2
• Cuffless and continuous noninvasive BP monitoring devices will
soon allow for a substantially
greater depth of understanding of
BP and its control.
1. Uhlig K. Annals of Intern Med 2013;159(3):185-194..
2. Green BB. JAMA. 2008;299(24):2857-2867

45. mHealth in Diabetes
1. Over 25 million US adults have diabetes, roughly 8% of
the adult population, while an additional 79 million are
pre-diabetic. 1
2. The total cost of diabetes in the US for 2012 was $245
billion, with $176 billion in direct costs. 2
3. Interventions that train patients in self-management and
improve their communication channels with providers can
significantly improve outcomes and decrease costs. 3
1. CDC. National diabetes fact sheet: 2011.
2. ADA. Diabetes Care. Apr 2013;36(4):1033-1046.
3. Aubert RE. Annals of internal medicine. Oct 15 1998;129(8):605-612.

46. The Next Generation of Glucose
Monitoring

47. Medicine Unplugged:
Bringing Solutions
Problem
1. Wellness
₋ Activity & Weight Loss
- Stress Management
₋ Sleep Optimization
- Cancer Prevention
2. Acute Disease Diagnostics
₋ Common Infections
3. Chronic Disease Management
₋ Hypertension
4. Medication Adherence
- Diabetes

48. Medication Non-Adherence
1. Only 51% of Americans treated for hypertension
are adherent to their long-term therapy. 1
2. About 25% to 50% of patients discontinue statins
within one year of treatment initiation. 1
3. Non-adherence causes ~30% to 50% of treatment
failures and 125,000 deaths annually. 2
4. Direct cost due to medication non-adherence are
estimated at $100 billion to $289 billion
annually.2
1. Choudhry, NK Pharmacoepi Drug Safety 2008;17:1189-1196
2. Ho PM. Circulation 2009;119(23):3028-3035.

49. mHealth Tools for Non-Adherence

50. mHealth Tools for Non-Adherence –
Ingestible Sensor (Proteus)

51. Circadian Pattern
Pill Taking Behavior
20
30
30
40
40
50
PERSON 1
Days
Days
10
20
Days
10
Taking Adherence
50
60
0
2
4
6
8
10
12
14
Time of Day
16
18
20
22
60
0
24
4
Average Circadian Pattern (+-std)
8
12
16
Time of Day
20
24
0
1
2
Pills Taken in Day
Timing Adherence
20
80
Circadian Pattern
Pill Taking Behavior
15
# Pills
Degrees
60
40
5
20
Taking Adherence
10
5
5
0
10
10
2
4
6
8
12
14
Time of Day
16
18
20
22
0
0
24
4
8
15
Days
Days
15
10
20
12
16
Time of Day
20
24
PERSON 2
Days
0
20
25
25
30
30
35
35
0
2
4
6
8
10
12
14
Time of Day
16
18
20
22
24
0
4
8
12
16
Time of Day
20
24
0
5
Pills Taken in Day

52. What will mHealth Technologies Mean for
Healthcare Providers?

53. Medicine Unplugged – Good News for More
than Just the Healthcare Consumer
1. In general, physicians are unsatisfied with their careers:1


Physicians rate the morale of 80% of their colleagues as poor to
very poor.
Two-thirds of physicans would not recommend it as a career to
younger individuals
2. ~80% of physicians rate the doctor-patient relationship to be
the most satisfying aspect of their work.1 However,


1.
2.
3.
4.
Today, average face-to-face time with a patient is ~10 minutes2
It would take between 11-18 hours daily for a PCP to provide all
of the preventative and chronic disease management required
for a typical patient compliment. 3,4
http://www.physiciansfoundation.org/
Gottschalk A. Annals of family medicine 2005;3(6):488-493.
Yarnall KS. American journal of public health 2003;93(4):635-641
Ostbye T. Annals of family medicine 2005;3(3):209-214

54. What mHealth can Mean for Healthcare
Providers
1. mHealth technologies will dramatically change the
practice of medicine, which, at first blush is very
concerning to physicians.
2. However mHealth will eventually free physicians of
being directly involved in precision, algorithmic
medicine that currently takes up a majority of their
day.
3. Instead providers will regain their primary role as a
diagnostician and educator allowing for longer and
more rewarding interactions for both patients and
providers.

55. Unplugged Medicine: Bringing Solutions to the Consumer
Healthcare Team
-Physician
-Nurse
-Pharmacist
-Dietician

56. Medicine Unplugged: Bringing the Solution to the
Problem through Mobile Health- Summary
1. Healthcare in the US is unsustainably expensive
and does not provide consumers with the kind or
quality of care they require.
2. mHealth technologies provide a starting point for
the complete re-engineering of healthcare that
engages and empowers consumers, improves
outcomes, lowers costs and improves satisfaction
for all involved.
3. Real world, large-scale demonstration projects
and/or pragmatic clinical trials are greatly
needed.