1. Healthcare

Perspectives
The Lancet Technology: January, 2015
Science Photo Library
Eric Topol
Test results from your
smartphone: flipping the
consultation room?
For more on Elle Dormer’s
experience with diabetes or to
attend a London seminar at the
Juvenile Diabetes Research
Foundation on managing
diabetes with CGM see https://
www.jdrf.org.uk/ or email
[email protected]
For more on Jessica Castle see
http://www.ohsu.edu/xd/health/
services/providers/index.
cfm?personid=2011
Photo Elle Dormer
For more on Eric Topol see http://
www.stsiweb.org/translational_
research/research_faculty/topol/
and @EricTopol
408
“It was life-changing from the outset”,
says Elle Dormer about the continuous
glucose monitor (CGM) her 4-year-old
son, who has type 1 diabetes, has had
for the past year. “For the first time,
we could make treatment decisions
in close to real time without the need
for endless finger stick tests.” The CGM
monitors his glucose concentrations
and relays this to an external handheld receiver, whilst a further
adaptation enables these results to be
sent to Elle’s smartphone.
Elle’s son’s glycated haemoglobin
A1c is exemplary for a child with type 1
diabetes, but the monitor has also given
them both freedom and reassurance
for normal day-to-day activities.
“Previously I was setting an alarm to
get up two or three times a night and
check on his blood glucose because he
had night-time hypoglycaemic attacks”,
explains Elle. “Now the receiver alarms
to signal rapid blood sugar changes and
hypos. Even when he is at preschool or
on a play date I can keep an eye on his
blood sugar.”
Jessica Castle, Assistant Professor of
Medicine (endocrinology, diabetes,
and clinical nutrition) at the Oregon
Health and Science University School
of Medicine in the USA, researches
CGM and uses CGM in the care of her
patients. “There is evidence to support
the use of CGM for improving glucose
control and reducing hypoglycaemia”,
she says. But Castle also acknowledges
that “CGM can be lifesaving, but the
choice of using the technology is a
personal one. It adds cost and takes up
additional ‘real estate’ on the body”.
CGM is just one example of the
many wearable health devices already
in clinical use. Other such devices
that have been approved by the
US Food and Drug Administration
include real-time ECG monitors,
blood pressure monitors, and even an
otoscope. As digital medicine advocate
Eric Topol, Director of the US Scripps
Translational Science Institute, points
out, ”another hundred plus sensors
will be launched this year”. Topol is a
practising cardiologist and also sits
on the board of directors or advisory
board for a host of medical technology
companies. “We are digitising human
beings, but it’s also a democratisation.
Wearable technology coupled with
the computing power of smartphones
places in the hands of patients
the ability to carry out laboratory
tests, and to monitor and diagnose
themselves without being dependent
on physician visits for tests. This
technology means that information
is transparent, the consumer or the
patient is not just engaged but knows
everything about themselves, and
rightfully so”, he says.
Topol’s view certainly fits with Elle’s
experience. “It’s very empowering”,
she says, “at hospital appointments
now I tell the doctor what has been
happening”. Elle, who lives in London,
says she still gets important advice
from her son’s medical team, but since
CGM is fairly new to clinical practice in
the UK a lot of her information on the
technology that is available and how
to use it comes from dedicated social
media forums.
Not all medical professionals are
convinced by CGM and other wearable
devices, expressing concerns that they
represent “high-cost, high-attention”
health monitoring which, far from
being democratic, is available only to
a minority of wealthy, well-educated
patients. In the UK, a complicated
application process to obtain funding
for these devices, and problems with
accessing devices currently marketed
only in the USA, mean these concerns
are a reality for many patients.
There are also questions around
data processing, privacy, and
security. Topol acknowledges that
“just collecting a huge dataset is not
enough, results obtained by patients
need to be processed and presented
in a consumer friendly way, and
one that can easily be shared with
the supervising physician without
affecting their time and attention”.
It seems clear from both consumer
level pricing and marketing that
many wearable medical devices are
being marketed directly to patients
themselves. Whether this technology
can really empower patients or
just represents another market for
medical device manufacturers remains
to be seen. What is undeniable,
however, is that the growth of such
technology calls for an evolution of
the physician’s role in advocating for
and educating patients.
In a fast-moving field it’s more
important than ever for physicians
to stay up to date with what device
manufacturers are offering—not
only to advise patients on what
works, how to access it, and how
to get the best out of it, but also to
evaluate the effectiveness and cost
efficiency of these devices, to push
device companies to deliver the
best possible product, and to ensure
government regulation protects
patients as consumers.
Naomi Lee
[email protected]
www.thelancet.com Vol 385 January 31, 2015