Ricky Bloomfield, MD, is director of mobile technology strategy and an assistant professor of internal medicine and pediatrics at Duke Medicine. He joined Duke in 2013 to oversee mobile technology initiatives within the healthcare system. In addition to rolling out apps associated with the Epic EHR, he is collaborating with multiple entities both inside and outside Duke to establish an open technology platform for innovation. During his residency, he founded a successful software company creating health and social networking apps for iOS devices that has enjoyed more than 12 million downloads to date.
He led the integration of Apple's HealthKit at Duke in August 2014 and is helping facilitate its use among interested faculty for both clinical and research purposes. He also provides guidance to other key initiatives across the health system, including telemedicine, a health accelerator, secure messaging, custom apps, clinical decision support and, most recently, integration of the open SMART platform.
Bloomfield completed his internal medicine and pediatrics residency at UNC Hospitals in Chapel Hill, N.C., followed by a pediatric chief resident year. You can follow him on Twitter @rickybloomfield or on his blog at www.rickybloomfield.com.
Q. What's the one promise of mHealth that will drive the most adoption over the coming year?
A. Beyond ubiquitous and reliable Internet connectivity, especially within the highest-risk demographics, the two most significant barriers to mHealth adoption have been the integration of these technologies into a user’s daily routine and then subsequent integration into the EHR – the “single source of truth.” Both of those barriers have taken a significant hit in the past year with technologies such as Apple’s HealthKit, which give a user the ability to choose how and when data will be shared – or not shared – and which do so securely and reliably using a device the user always has with him or her.
Q. What mHealth technology will become ubiquitous in the next 5 years? Why?
A. I can’t overstate the importance of the role wearable devices will play in revolutionizing how we care for patients. For the first time in history, we have relatively low-cost computers that are in constant contact with our skin and are comfortable to wear. This opens the door for the R&D of sensors that allow for continuous monitoring of vital signs and other metrics that we’re just now learning to interpret. Wrist-worn technology has kicked-off this trend, but it most definitely won't stop there; this technology will eventually become a seamless and transparent part of our wardrobe and daily routine.
As a physician, I’m intimately familiar with the limitations of clinic visits to assess patient health. A patient with a reasonably controlled chronic medical condition such as congestive heart failure may have a 15-minute clinic visit once every 1-3 months. The measurements taken at that visit will form the basis for that physician’s medical decision making until the next visit. However, even that chronically ill patient will spend more than 99 percent of his or her life outside the medical setting. Understanding what happens in that other 99 percent will allow us to make better decisions sooner. Improvements in wearable technology and the software to facilitate gathering that patient-generated data will change how we practice medicine.
Q. What's the most cutting-edge application you're seeing now? What other innovations might we see in the near future?
A. Anything compatible with the SMART on FHIR platform. Just as Apple and Google have standardized the ability to write, package and install apps that work seamlessly on hundreds of millions of personal devices, the SMART on FHIR platform will enable a new generation of mobile and web apps that “just work” with all EHR systems that choose to implement the standard. This will result in a rapidly growing and stable platform which aspiring mHealth entrepreneurs can target, thus reducing development complexity and cost while increasing the potential market share.
Q. What mHealth tool or trend will likely die out or fail?
A. Head-worn technologies such as Google Glass haven’t yet come into their own. Use cases are few and far between, and all implementations to date have fallen short with key deficiencies in software, battery life and user interface. For a device like this to be successfully implemented in healthcare it will need to be invisible to the patient (possibly resembling a normal, non-bulky set of glasses) with a more intuitive interface. In the interim, the majority of use cases requiring hands-free access to data could be accomplished by current and upcoming wristworn devices.
Q. What mHealth tool or trend has surprised you the most, either with its success or its failure?
A. I’m very excited to see the results of the Tricorder XPRIZE. Devices such as the Scanadu Scout are demonstrating the ingenuity of healthcare technology teams when properly motivated. These devices will pave the way for seamless and continuous integration of transcutaneous sensors into our daily lives. Making good medical decisions starts with collecting high-quality information, followed by quick and secure transmission of that information to a medical professional. Eventually, of course, the medical professional will by bypassed completely, and these devices will allow for rapid, automatic analysis and diagnosis (subject to FDA approval). As a physician, I personally can’t wait for technologies that make me obsolete. This is the only realistic way to solve the growing physician shortage in the U.S. and especially in developing nations.
Q. What's your biggest fear about mHealth? Why?
A. MIT called 2015 the “Year of the Hospital Hack,” and less than two months into the year we became aware of a breach at Anthem, the nation’s second-largest insurer, in what could be one of the largest health-related information breaches to date. As greater numbers of users put more of their personal health information on their devices, this risk will only increase. We need to be careful that in our excitement to implement these technologies we are not taking shortcuts regarding the security and privacy of patient information.
The solution is part technology and part policy. With Apple’s HealthKit, for example, health information is saved to the device only, never being directly synchronized between devices via iCloud. By policy, Apple prohibits other apps from doing the same. This dramatically decreases the potential attack surface. It is then up to the user to decide with which services the information is shared and to what extent.
Q. Who's going to push mHealth "to the next level" – consumers, providers or some other party?
A. For mHealth to succeed, we ultimately need to make sure that what we’re doing is in the best interest of the users – our patients. If users don’t see an obvious upside, or if the intervention doesn’t provide a short-term benefit, it will fall into disuse. For example, if monitoring weight and blood pressure in a pregnant woman allows her obstetrician to reduce the number of required prenatal visits, thus saving her time, money and inconvenience in the short-term, she’ll be more likely to be compliant with the measurements.
However, the innovations must be built on the foundation of a reasonable business model. New E&M billing codes such as 99490 open the door for sustainable telemedicine, allowing hospitals and clinics to be reimbursed for the effort they spend to care for patients remotely, ultimately saving patients money and keeping them healthier. As more payers become willing to reimburse for these codes we’ll be able to move beyond the current implementation/reimbursement standoff and usage of these technologies will dramatically increase.
Finally, continued FDA guidance on this issue will help define boundaries between those applications that require oversight and those over which the FDA will exercise enforcement discretion. While current guidance is non-binding, it provides valuable guideposts that should promote and encourage innovation while ensuring patient safety.
Q. What are you working on now?
A. Here at Duke we’re continuing to explore and scale technologies that will allow our providers to take better care of patients. Currently, HealthKit is the most promising technology to facilitate the secure and high-quality transmission of patient-generated data to our EHR, and we have plans to appropriately scale this technology. Google Fit could possibly play a role in the future once more relevant healthcare data elements are standardized and incorporated into the platform.
Once we have the data, we need to make meaningful use of it. This will be accomplished through advanced analytics and visualizations that will be presented to our providers as part of their workflow, whether on the desktop or mobile. SMART on FHIR-based applications will help serve this role. We are currently developing and testing several SMART on FHIR apps and have incorporated the platform into our Epic-based EHR.
Finally, we need to enable and reward the innovators who are making this work a reality. The Duke Institute for Health Innovation is now in its second year of funding projects that show the greatest promise to improve health and reduce cost. Most of these projects involve technology integration, and the robust platform we’re developing will enable this new generation of scalable and integrated healthcare apps.
Editor's note: Bloomfield has a busy schedule at the HIMSS15 Conference and Exhibition in Chicago next week, which begins this weekend. He's scheduled to present at four educational sessions: "Achieving a Functioning Learning Health System by 2024 – The Challenges and Benefits of a Successful Journey," "C-Suite vs. Developers: mHealth Wants vs. Needs Showdown," "HIMSS mHealth Case Study: Duke's HealthKit Experience" and "SMART on FHIR: Apps for Health."
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