Technologyreview.com, February 20, 2004

Your Daily Digital Doctor

Advanced analysis of home medical data can offer continuous care for patients with diabetes and other life-threatening chronic diseases.

By Eric Bender

Eighteen million people in the United States suffer from diabetes, and the disease cuts their average life expectancy by ten years or more. To keep the condition under control, they need to juggle diet, medication and exercise. And that can be a huge struggle even with the best treatment available.

But very few of those afflicted in this fast-growing epidemic get anything like the best treatment.

Most patients don't get care from a specialist, don't take enough tests to properly track the disease, and fail to adopt changes in diet and exercise that can slow or sometimes stop the disease's progress and the onset of ugly complications, say healthcare experts. The general quality of diabetes treatment is "pretty embarrassing," says Alan Moses, senior vice president and chief medical officer for the Joslin Diabetes Center in Boston, the largest U.S. center of diabetes research.

Ideally, a patient with an incurable, life-threatening disease such as diabetes would take critical medical measurements at home each day, and immediately get advice from his or her doctor.

While that remains impractical, new hope is on the horizon for digital monitoring systems that will help to fill this yawning gap-and to provide clues to each patient's treatment that no doctor could ever gather manually. This summer, Joslin will partner with Boston startup InterMed Advisors on a trial of one such alternative-a soup-to-nuts home monitoring system for diabetes patients. The InterMed project will combine patient education, daily in-home monitoring of blood glucose levels, and advanced analysis of the wealth of resulting data. It will also alert clinical staff as needed, and provide patients with daily, individualized feedback.

This systematic approach is one of the most ambitious ever undertaken in home patient monitoring. Ultimately, such home systems could raise the level of care not only for those with diabetes but also a variety of other potentially deadly chronic conditions, including heart disease and pulmonary ailments. Not so coincidentally, the monitoring systems also aim to save big bucks on the cost of home health care, emergency room visits and hospitalization.

Data-Driven Feedback

Because it can be so tricky to manage, diabetes is a poster child for patient monitoring systems. "Diabetes is a complicated disease, and it requires lots of behavior changes," says Medha Munshi, a Joslin physician working on the InterMed project. "It's really patients who manage their disease." Diabetes is caused by problems with insulin, a hormone that regulates how your body metabolizes glucose. In type 2 (adult onset) diabetes, your body doesn't produce enough insulin or can't handle insulin properly. In the far rarer type 1 (juvenile) diabetes, your body stops producing insulin altogether. In both cases, blood glucose levels soar-a condition that damages almost every part of the body.

Type 2 patients struggle to control the disease by restricting their diet, exercising, and often by taking one or more drugs. Keeping blood glucose in the proper range is a juggling act, often exacerbated by other medical conditions and the accompanying drugs. Illness, stress, schedule changes, and other variables further complicate the picture. Patients must monitor themselves daily and adjust their behavior as needed. While many have limited success, others don't understand the procedures-or find the effort too burdensome and don't even try.

InterMed's process, first tested in preliminary experiments last year, begins by educating patients about the disease. Then the company installs the monitoring system, with devices to measure blood sugar, blood pressure, weight, and physical activity (as gauged by a device that detects the patient's motion, skin temperature and galvanic response). Readings are automatically sent to a wireless home hub, which uploads the data once per day through the Internet to the system's central database.

Once the system is up and running, data are analyzed by InterMed's patent-pending software. Alerts are generated for healthcare workers as needed-if, for instance, blood glucose levels keep running high. Finally, the system generates a "daily prescription for living," with individualized advice. InterMed plans to deliver this advice by a "virtual doctor" or "virtual nurse"-a simple animation of an actual clinician that appears on the patient's TV or computer screen. "The interactive model is the key to keeping patients involved in their care," says Munshi.

"They need to have a sense that what they're doing is working," adds InterMed founder and CEO Richard Rosen.

They Went Data Way

InterMed employs a battery of mathematical approaches to crunch through all the measurement data and find out the combination of factors that's driving each individual's blood glucose levels. The system analyzes individual readings (such as blood glucose) over time, correlates these readings with other parameters, and estimates the value of taking specific corrective steps.

"We rely on time-series data, which turn out to be very rich in information if you analyze them correctly," says Rosen. "When you apply rigorous analysis to these kinds of data, some things you thought were true aren't true." After gathering three months of data, Rosen claims, the system can predict unwanted events, such as an emergency room visit, as far as two weeks in advance. That prescience enables physicians and other clinicians to work with the patient to avoid crises.

This approach to patient treatment "needs to be proven, and it will take time, and lots of patients, to prove it," cautions Joslin's Moses. "But it is potentially very valuable, especially the use of time-series analysis, in which each patient becomes his or her control [sample] over time."

The InterMed/Joslin initiative is just one among many programs in home patient monitoring, which began in simple form decades ago. Now there's a tremendous range of digital home monitoring devices, for conditions ranging from asthma to cystic fibrosis to HIV/AIDs to recovery from surgery. And hundreds of thousands of patients already participate in programs run by disease management firms, home healthcare services, and other groups.

More than 100 companies are offering home medical monitoring products or services, attacking this market "in every way you can think of," says Vince Kuraitis, principal of Better Health Technologies, a consultancy in Boise, Idaho and a leading authority on such systems. While precious few of those companies are profitable, "this market will be huge-all the arrows are pointing up," he predicts.

Costs of monitoring devices are coming down, and products are getting friendlier, Kuraitis says. But those offering services must work within the current system; for instance, doctors must receive alerts about their patients in an appropriate way. Early systems often assumed the doctor would be glued to the system that delivered this info. But most doctors won't work that way.

One disease management company that says it has learned how to work within the system is LifeMasters Supported SelfCare of Irvine, CA. Lifemasters serves more than 300,000 patients with various chronic illnesses, says Derek Newell, vice president of outcomes measurement and product management. Patients send in data via phone or the Web, or use monitoring devices that automatically collect and submit their data. Nurses call patients at scheduled times or when there are warning signs. If the patient confirms the warning signs, the nurse alerts the patient's physician-usually via fax and follow-up phone call, since the company has found that works best. Newell says the LifeMasters software also integrates patient data from other sources-pharmacies, for instance-and updates the patient's profile when new data come in.

San Diego-based CardioNet takes a different tack. It concentrates on a single condition: atrial fibrillation, a common form of heart arrhythmia. Patients who have, or might have, such irregular heartbeats are monitored for a week or two while they go about their lives. The patient wears an electrocardiogram sensor that broadcasts wirelessly to a Palm-sized device. Held in a pocket or a purse, this unit stores the data and sends it via cellular phone link to a monitoring center staffed by cardiac technicians.

CardioNet's system detects heart events that could not otherwise be analyzed and gives data that are far more representative than what you can gather in a hospital test, says vice president Larry Watts. That way, he says, cardiologists can prescribe the most appropriate treatment. CardioNet got FDA approval for the service in 2002. After piloting in the Philadelphia area, it is now expanding nationwide and has served thousands of patients.

Consumer-Driven Technologies

Home medical monitoring programs like these "play to a major trend of moving healthcare from hospital and doctor's office to the home," says Joseph Coughlin, director of the MIT AgeLab, which investigates technologies that promote lifelong health. They also follow the 800-pound-gorilla of demographic trends: a population that is aging, and thus more susceptible to chronic disease. "One baby boomer turns 50 every seven seconds," Coughlin notes. Boomers will accelerate the shift toward driving healthcare by consumer demand, he predicts. "They will prefer personalized, real-time, home treatment."

Herschel Peddicord, founder and CEO of HomMed, a Brookfield, WI, company that manufactures home monitoring systems, agrees that consumers will play an ever-increasing role in maintaining their health-and will look for better technology to do so. "Do you have a VCR in your home?" Peddicord asks. "A DVD player? A microwave? Okay, how many devices do you have to make sure you're going to live tomorrow?"

In time, Peddicord predicts, you'll go to a consumer electronics retailer such as Best Buy and pick out health monitors for your family.

Limits on the population of medical professionals also will help to drive home health monitoring, Peddicord says. The United States is now short many thousands of nurses, and healthcare experts expect a growing shortage of physicians as well. "With the baby boomers aging, who is going to take care of these people?" Peddicord asks. "Why not use technology to bridge the gap?"

Coughlin, however, predicts that the biggest point of new consumer-oriented systems will not be to replace clinicians but to do a better overall job on healthcare. In the long run, "the hard part is not the technology," he adds. "The hard part is changing patient behavior."