THE REVOLUTION IS ON
A local doctor-turned-inventor is part of a revolutionary move toward mobile devices as medicine ‘shifts left,’
Mobile tech takes health care by storm
Jacob Blackburn loves competitive swimming and Harry Potter.
Half-day treks to the Children’s Hospital of Eastern Ontario from his family’s home near Carleton Place? Not so much.
But 15-year-old Jacob — who was born deaf in one ear then began losing hearing in the other — needed to undergo the frequent tests to puzzle out why his remaining hearing fluctuated so wildly.
Enter Dr. Matthew Bromwich, who sent Jacob home with Shoebox — a novel iPad audiometer that looks more like a video game, so he could check his own hearing at home every day.
“I would see the reports right after I did it and I’d email it to Dr. Bromwich and my mom and dad so they could see it, too,” Jacob explained. “I didn’t have to go anywhere. It was nice to be able to do my homework instead of having to stay up late and finish it. It gave me time to do swimming and not skip my practices.”
But it also allowed Bromwich to start assessing Jacob’s hearing loss and, eventually, it let the teen and his family make the decision to go ahead with a cochlear implant, sometimes dubbed a bionic ear.
“It’s given us the tools to start helping him,” Bromwich said.
The result has been life-altering, said Jacob’s mother, Jennie.
She said that after putting in the hard work to learn how to translate the electronic sounds, her teenage son now relishes even the little things, such as hearing the family dog’s nails clicking on the floor or knowing that a jet is overhead.
“It’s making a huge difference to his life,” she said.
Shoebox is one in a string of innovations that are on the market or on the way from Bromwich’s Ottawa-based Clearwater Clinical. The 41-year-old CHEO ear, nose and throat surgeon and assistant professor at the University of Ottawa, founded the company in 2005 with three fellow research scientists, his software-developer brother Julian, and $10,000 of their own cash.
They ’ve since secured $7 million in funding for what Bromwich calls a social enterprise. Its deceptively simple aim is to use mobile technology to replace traditional equipment that’s costly, outdated or simply not available where it’s needed.
“This really is a revolution in terms of health-care technology,” Bromwich said.
For decades, health care has “shifted right.” It’s become more expensive and has been centralized in the most expensive place, Bromwich said: the tertiary care hospital.
“What we need to do is shift left,” he said. “We need to empower the primary care, the community members, the nurses, the outreach workers, the home care. We need to empower all of those people to deliver quality care outside of the hospital.
Talk of tech is everywhere these days, from the Ontario government appointing a chief health innovation strategist as part of what’s now a nearly $52-billion-a-year health file, to $50 million being allocated over two years in the federal budget for the Canada Health Infoway, which aims to spread health technology from coast to coast.
The new federal minister of health’s mandate includes fostering collaboration across the country to encourage the use of new digital health technology to boost access, efficiency and patient outcomes.
“That’s really, I think, the future,” Bromwich said. “We can’t keep shifting right all the time. You can’t possibly have health care cost more than 60 per cent of our provincial GDP. You can’t say, ‘You live far away, I’m going to give you worse health care’.”
Clearwater Clinical was born out of frustration that there were bulky video towers in hospitals — which cost $60,000 to $100,000 — but that they were not specifically where staff needed them: in the emergency rooms, the ICUs or on patient floors.
Hence the conception of Clearscope, a hand-held adapter that links any endoscope — a flexible tube with a light on it — to a smartphone.
With the help of a nurse, Dr. Jean-Philippe Vaccani recently demonstrated at CHEO how the adapter allows the endoscope he does of a child’s throat — often in an attempt to explain breathing problems or find a swallowed object — to be recorded, shared and played back.
A resident can scope a patient in the emergency room and send the video to Vaccani’s cellphone at home, getting an instant consult and preventing the patient from having a tube stuck down their throat a second time. The doctor can use the video to teach a medical student or to explain what’s happening to a child’s worried parents.
“With one shot, it’s recorded, it’s saved and I can see it at home on a safe, secure portal and give feedback instantly,” Vaccani said. “Now you can actually show a family member what it looks like.
“It’s incredible how technology has changed the way we do things. Often it means quicker answers for them.”
Increasing clinical use of doctors’ smartphones posed another challenge for Bromwich: safeguarding patients’ privacy.
Clearwater’s Modica app allows them to separate and encrypt clinical images and video and to securely store, annotate and share them.
The intention is to make the app a workspace. It could help specialists in any hospital, for example, collaborate on surgical and pathology reports or diagnostic test images for a single cancer patient, or allow a family doctor to get help on a challenging case.
Over time, patterns found in “big data” — such as thousands of images of the same medical condition — will be revealed, Bromwich said.
It could also change home care, where nurses currently visit a postoperative patient, look at a wound and fax their opinion to the surgeon who decides what happens next — a system Bromwich calls archaic.
In London, Ont., a urology surgical unit is instead using Modica to allow nurses to take pictures of the wound and send it to the surgeon, who can then determine whether the patient is healing well at home or needs to be seen again.
The next step is to open up a new form of communication, like a companion app for patients, many of whom already come in armed with their own cellphone pictures.
“I think everyone has had the experience where they go to the doctor and say ‘It was really bad yesterday, but it kind of went away today’,” Bromwich said.
He envisages a way for patients to be sent home with a digital reminder to take further pictures they can share electronically, reducing unnecessary followup visits.
It’s not just convenience and cost. Bromwich argues that mobile technology has already proven itself to have life-saving applications.
There was the doctor in a remote community who shared on Modica an X-ray of a three-yearold he thought had swallowed a coin. Bromwich realized what was lodged in the child was a round battery, which could leak lethal acid. The child was airlifted to CHEO to have Bromwich remove it right away.
Another time, there was a youngster in his clinic with strange skin lesions, so Bromwich sent an image to a dermatologist colleague who immediately identified an extreme form of psoriasis that can be deadly without quick treatment.
Or there was the child with bleeding around a tracheostomy — a hole made in the throat where a tube cab be inserted to help a patient breathe. A resident’s scope looked clean but, viewing the video, he detected erosion that threatened a major artery in the neck. The child, at risk of dying of blood loss in minutes, was rushed to the operating room.
“The whole point of health care research is to improve the lives of the people around you,” Bromwich said. “One of the greatest satisfactions of doing this work is these things have become medical innovations and people are using them.
“We are doing these things to be used, to help the situation in Ontario, to decrease the cost, to provide better care closer to home, to shift left. We are doing it all for those reasons.”
Coming up with solutions tailored to on-the-ground challenges is what impresses Ontario’s new chief health innovation strategist most about Clearwater’s products.
“It doesn’t always happen that way,” William Charnetski said. “If I had one wish, it would that we were able to articulate in the health care system our demands quite clearly and therefore set them as priorities and allow people like Matt to come up with the solutions to these challenges.
“That immediately struck me about the work.”
Charnetski was appointed last September after the Ontario Health Innovation Council struck by the province advised it to establish an office to oversee a string of initiatives.
It will use “innovation brokers” to make sure new technology matches what patients need and to connect tech developers with funding, back homegrown technology to the tune of $20 million over four years and find the “pathways” to get new health technologies into use.
In Ontario’s massive health-care system, “taking advantage of these opportunities to enhance quality of life and reduce health care costs is critical,” the council concluded.
The challenge of bringing healthcare to people, rather than people to bricks-and-mortar is where mobile and virtual technology presents the most exciting possibilities, Charnetski said.
The first things Charnetski’s office will be targeting for farreaching reviews are virtual care through technology such as video links and mobile health. The intent is to use wireless technologies, such as smartphones and tablets, to help people manage their own care, find their way around health services and track health information.
Some of those possibilities are highlighted by just a few examples already underway from the Ontario Telemedicine Network (OTN).
They’re piloting the use of the website bigwhitewall.com with 1,000 patients to see whether access to round-the-clock trained counsellors, peer support and resource library via computer, tablet or smartphone will help people struggling with mental illnesses such as depression and anxiety, especially those on wait lists for help.
Meanwhile, OTN is helping the province’s family doctors learn to use proven virtual tools, such as “eCare” apps and programs that monitor and coach their patients to manage chronic diseases at home.
“It will become increasingly powerful in the hands of the patient,” he said. “I would encourage people to really get to know technologies that people like Matt Bromwich are developing.
“There are such incredible things happening and the more that people are aware of the potential for things like mobile and virtual technologies, I think, the more they will expect them in the health-care system, the more likely the health-care system will adopt them.”
While experts and officials are trying to bring mobile technology into the health-care system, Canadians are already adopting it in droves on their own.
Seven in 10 Canadians with Internet access already use mobile health applications and devices. It’s a growing field that’s come to be known as mHealth.
Health Canada only gets involved in the licensing of apps it considers higher-risk, because they aim to diagnose or treat illness. But Canadians are using this type of technology to quit smoking, keep up to date on their kids’ immunizations and even to track family members with dementia using GPS chips in shoes, notes the Canadian Agency for Drugs and Technologies in Health (CADTH) in one tech update.
Meanwhile, technology developers complain that investment in “brilliant ideas” doesn’t pay off by having them widely adopted.
The Ontario Health Innovation Council, in fact, has noted that too many developers find their innovations fall into the “valleys of death” — the first between concept and prototype, the second between pilot and adoption, with pitfalls that include a lack of seed money and going without the chance to get feedback from doctors and patients, the council found.
The independent CADTH acts as an “honest broker” in assessing the effectiveness of new technology for policy-makers and doctors and works with companies to help them develop the base of evidence they’ll need to sell innovations.
Dr. Tammy Clifford advises innovators to take a broader view of proving their products. She’s the vice-president of medical device and rapid response programs at CADTH and an adjunct professor at the University of Ottawa.
“Collect the data that could show what’s happened,” she said.
“Are you able to diagnose a patient sooner or get them into a specialist faster? Does this change throughput of the system? Does it enable a clinician to do more of something or different things? It’s a pretty broad ask, but it’s important to consider all of those facets and to even think about longer-term outcomes.”
Often a simple cost analysis is hard to do because the impact goes beyond hospital walls, Clifford said. She calls the Blackburn family’s experience with Shoebox a perfect example of how technology could prevent a young patient, and even siblings, from missing school and parents from losing work days.
That’s on top of the intended benefit of maximizing Jacob’s hearing and quality of life.
“It’s challenging to get people to understand that,” Clifford said.
“It goes back to getting the system to be synced up, joined up. The technology is purchased by the health sector, but then the savings are seen somewhere else in the system — it’s trying to get people to step back and take a societal perspective.”
Two things either push or block the adoption of technology — the evidence it works and a system that’s ready to make it happen, Clifford said.
“There’s no doubt about it, technology is here, it’s a part of our dayto-day lives,” she said.
“How can it be harnessed to enable better patient care and a more efficient health-care system? It’s time for proven technologies that can be integrated into the system. It’s just time.”
The technology is purchased by the health sector, but then the savings are seen somewhere else in the system.