Mobile health technology raises questions of liability

Jane Von Bergen
The Philadelphia Inquirer

PHILADELPHIA — The airline passenger was in deep trouble - not breathing, no heartbeat- when a fellow passenger, Raina Merchant, then a resident in emergency medicine, tried to save his life.

"The patient survived the flight, but, sadly, not much longer," said Merchant, who performed cardiopulmonary resuscitation on the passenger.

That was seven years ago.

Now, Merchant, a Penn physician whose research centers on resuscitation, is developing a mobile-phone application that would, with one push of a button, provide oral instructions for CPR. The app would even say, "Press, press, press" to allow the right rhythm for chest compressions.

More and more these days, the same smartphone technology that allows tourists to find the best latte nearby and bystanders to become instant video journalists at a natural disaster is making its way into the world of medicine and health.

It's a big business. Pricewaterhouse Coopers' Health Research Institute estimates the annual consumer market for remote/mobile monitoring devices to be $7.7 billion to $34 billion a year, based on its surveys. In August, Apple iTunes reported that there were 10,000 medical and health care and fitness applications available for download.

That's just the consumer market - there are already many examples of wireless technology now being used by doctors, hospitals, and other health-care providers.

Benefits and questions
"So many different health apps pop up," said Joseph Kim, a doctor of internal medicine whose bachelor's degree is in mechanical engineering. "How do you as a consumer, or as a physician, know which ones are reliable or which are accurate?

"Unfortunately, the technology is moving faster than any regulatory body can keep up," said Kim, a vice president at Medical Communications Media Inc. in Newtown, Pa., and a specialist in the use of technology in medicine.

"Releasing an app is very easy," he said, but if it is developed abroad, the standards may be different than they are in the United States. For example, a recommended drug may be approved elsewhere, but not in this country.

"There are a lot of questions of liability that have yet to be answered," Kim said. "If a patient uses an app on the iPhone, who, at the end of day, is liable? If someone buys a WebMD Symptom Checker and there's a problem, is the Apple Store liable? Is WebMd liable?"

WebMD provides a disclaimer. "This tool," it says on the website for its iPhone app, "does not provide medical advice. It is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment."

Speaking to a gathering of health care journalists in Philadelphia this month, Kim said that the wireless "future is certainly bright, but we have to be very cautious. And given that technology is moving so fast, we have to be very, very cautious."

A wealth of possibilities
Mohit Kaushal, chief strategy officer of West Wireless Institute, a nonprofit research and development organization in California, ran through his vision for the future.

"The right care, at the right time, wherever the person may be," he said, joining Kim on a panel at the Association of Health Care Journalists convention.

That right care, for a forgetful elderly person, could include a smart pill box that sends a message to a caregiver, perhaps a son or daughter, if the pill box isn't opened for a day or two.

"It could send a message: 'Your mother isn't taking her medicine,' " he said.

West Wireless has developed its own technology, Sense4Baby, that collects maternal and fetal data, such as blood pressure and fetal heart rate, from a patient at home or in a local clinic and sends it via mobile technology to a doctor who can diagnose from anywhere.

Especially useful for mothers who have had previous pre-term labor, the device could achieve up to $14,000 in savings by providing less expensive monitoring, the company says. It also would be useful in places where physicians are few and transportation to a hospital is difficult.

Skin patches affixed to patients' chests after they have been admitted to the hospital for problems related to congestive heart failure could monitor them when they are released and send data to a receiving station, with the ability to alert someone when the data show dangerous abnormalities, Kaushal said.

Readmissions for congestive heart failure cost the health system $7 billion per year, he said, adding that physicians would get an "understanding that things are going wrong earlier in the cascade of disease."

That's fine, theoretically, countered John Kairys, a surgeon and endocrinologist from Thomas Jefferson University Hospital who also addressed the Association of Health Care Journalists. All this data-sending assumes that someone qualified is available to read it.

"Who is sitting in the office monitoring all this?" Kairys asked. "No one is being reimbursed for that. If I have to hire someone in my office to do that, where am I going to get the dollars to pay that salary?"

Many physicians, Kairys and Kim agreed, are already familiar with some applications, such as Epocrates, which provides information on drug interactions, pricing and dosing via BlackBerry, Android, iPhone or Palm.

But how conversant, Kim asked, are physicians with the many off-the-shelf medical apps for consumers?

Raina Merchant hopes that her off-the-shelf CPR-coaching app will be ready for consumers soon.

"There's almost no downside to it," she said. "If you do nothing, the patient will definitely die."

And even though she's done CPR many times, Merchant said she'd still use the CPR app if she found herself in a situation similar to the one she faced on the airplane.

Her research has shown that hand placement and the quality of chest compressions are improved with oral coaching, no matter how much previous training the rescuer has had.

"There are a lot of mechanics to remember," she said. "In that moment, when it's you and that person, it's quite a task. But we want people to think they can do it."

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