NEW ORLEANS -- Wearable health devices are beginning to show promise, but physicians need to be aware of the current limitations of the devices when working with patients who use them, several speakers said here.
Until recently, most use of wearables was physician-driven, Avital O'Glasser, MD, of Oregon Health and Sciences University, in Portland, said at the annual meeting of the American College of Physicians. "We use wearables already -- and have for decades," she pointed out, citing the telemetry monitor and home Holter monitor as examples. The difference is, "patients are now coming to you and saying, 'I have this' or 'I want to buy this app' -- and what do we do with that information? How do you gather this, bottleneck it, and streamline it into something meaningful?"
This becomes especially important as practices move toward doing more population health management, said Priya Radhakrishnan, MD, of HonorHealth Medical Group, in Phoenix. "We have to figure out how to collate the data, integrate it into the electronic health record [EHR] and actually prescribe a plan for patients."
Increased use of wearables has the potential to reduce costs "tremendously," she continued. "You're not sending the patient for a sleep study or [using the] Holter monitor ... It has the potential to disrupt a lot of our medical testing. It's an area where, from a business perspective, you should be paying a lot of focus to."
Take, for example, a patient with obesity who isn't quite ready to make a change in his or her lifestyle. "If you send somebody in a sort of 'pre-contemplative' stage [out] with a tracker, that may help them see how many calories they're using and move them into a 'contemplative' stage; then they're primed" to think about making a change.
A useful wearable will have several important attributes, said Alisa Niksch, MD, of Tufts University, in Somerville, Mass.:
- Accurate: "We want them to be studied against conventional standard-of-care devices; we want more continuous data rather than episodic [data]," she said. "And contextual data also is very important -- instead of just measuring [the patient's] heart rate, maybe there is something that gives you an indication of what the patients are doing" when that heart rate is being measured
- Filtered: "Physicians don't like loads of data or extra work to muddle through." At the same time, "We do want to be notified when our patients take a turn for the worse. If there's an indication that something is happening that we need to take action on, that needs to be something the platform lets us know about"
- Integrated: "We want the data to be integrated into the EHR, so the use of open source APIs [application programming interfaces] and NL7 standards is very important," said Niksch. "Wearable data are not automatically uploaded into EHRs; obviously, we want that. We want health information technology platforms that incorporate patient-generated data by 2020. And the data -- like an EHR -- should be interoperable. "We've had some whispers with Apple that they're trying to develop a personal health record," she added. "Wearable data has a much higher probability of being integrated into the phone and the EHR, but personal health records are also vulnerable to third-party access if they interface with institutional EHRs," such as employee health programs
- Passive transmission: "The more passive we make it, the better it is, since patients aren't always reliable about transmitting their data"
The data transmission should also be secure. In 2015, Fitbit's maker started the process of making sure its device was compliant with HIPAA [the Health Insurance Portability and Accountability Act], "which is an indication of their pathway to being more of a medical device," Niksch said.
The lack of data on wearables -- whose market is estimated to be $24 billion by 2022 -- is quite noticeable, according to Niksch. One analysis looked at 4,328 studies of wearable biosensors -- specifically, fitness trackers -- and identified only 64 randomized controlled trials. Of those, only 16 were determined to be of high quality. "Fitness and wearables are an expanding market; we need more research on outcomes," she said, noting that the Department of Veterans Affairs is doing a study using a wearable to track post-myocardial infarction complications as well as heart failure indices.
Physicians who work with patients using wearables should be aware of the legal issues surrounding them, said Radhakrishnan. "You can have a patient who says, 'I sent my heart rate monitor information to you ... and oh, by the way, I had a stroke.' So if you have a patient using a wearable, make sure you have clear policies and procedures" in place regarding liability for using, she said.
Getting reimbursed for doing work with wearables also remains an issues. "Chronic care management codes are where one can get some reimbursement," said Radhakrishnan, citing codes 99490 (Chronic care management services), 99487 (Complex chronic care management services), and G0505 (Cognition and functional assessment) as examples. "If you are part of an accountable care organization or Medicare Shared Savings program, those are [organizations] where there is a good chance you'll get reimbursed [for this]."
Whether or not you are currently prescribing wearables to patients, make sure you develop a plan for working with those who are using them, O'Glasser told 鶹ý in an interview. "The starting point is to set a meaningful goal," she said. "If a patient says, 'I want to increase my activity level,' [you can say], 'OK, start with 5,000 steps a day and come back and see me in 2 months ... Have that conversation. For all the technology, it still comes out to the conversation at the bedside."