Wednesday, April 29, 2015

There's No Place Like Home

Once upon a time -- no, this isn't a fairy tale -- much of health care happened at home.  You were born there, your doctor made house calls, and you probably died there.  Then came the "modern" era and gradually more and more health care happened elsewhere -- a hospital, a nursing home, an ER, an outpatient facility, or a doctor's office.

That may no longer be progress.

Take, for example, the Hospital at Home movement.  Originally developed by physicians at Johns Hopkins and now also in place at several other institutions, it seeks to identify patients who can remain at home with targeted support, rather than being admitted to a hospital.  Writing in The New York Times, Daniela Lamas, M.D., profiled such efforts at Mt. Sinai Hospital (NYC) and Presbyterian Healthcare Services Hospital (Albuquerque).

The trick, of course, is to identify the right patients.  Johns Hopkins originally started with four diagnoses, and the list is gradually being expanded.  The program has already demonstrated its effectiveness in several studies, including one looking at Presbyterian Health Services' efforts.

Dr. Bruce Leff, one of the original founders of Hospital at Home, predicts a changing future for hospitals: "My sense is that over time, hospitals will become places that you go only to get really specialized, really high-tech care."  I hope he is right.

Sometimes patients in such programs can still end up needing to be hospitalized, but Presbyterian Healthcare Services, for example, says this only happens 2.5% of the time.  That means a lot of averted admissions, and a lot of happier patients.

Dr. Leff has described hospitals as "toxic" for patients, and he's not speaking only metaphorically.  An article in the Wall Street Journal about the Hospital Microbiome Project points out that 1 in 25 hospital patients acquire an infection there, killing some 75,000 patients each year.  Half of the infections are due to bacteria that have become specialized in hospitals.

As is true with virtually all microbiome research, these researchers are finding eye-opening numbers and diversity of bacteria.  I especially was struck by one finding:  "Typically, people came in and out of each room 100 times a day, trailing invisible plumes of bacteria."

All things considered, I'd rather stay at home.

The home movement isn't just about avoiding hospitals, of course.  I've already written plenty about telehealth, which can help avoid office visits, and I don't need to cheer it on further here.  Instead, look at home-based diagnostics.

One highly touted start-up is Scanadu, which analysts love to describe as offering a medical tricorder.  Dr, McCoy might disagree, since Scanadu's Scout currently can "only" check temperature, blood pressure, and heartbeat.  Scanadu expects to soon offer a urinalysis test, Scanaflo.  According to The Wall Street Journal, Scanadu also hopes to eventually offer a blood sample and nucleic-acid diagnostic device that can provide information on blood-cell count and genetic markers, which can provide early warnings of health problems or risks.  Dr. McCoy might start to be more impressed.

Scanadu sees its devices as consumer devices, and is getting FDA approval for them.  CEO Walter De Brouwer thinks he's in the data business, not the hardware business, telling Fortune: "The data will eat physiology...there will be triple or quadruple Moore's Law in these things, and it will go through the phone which is the remote control of our world."

I might quibble that the data still relies on the physiology, and that even the smartphone has a limited lifespan as our data intermediary, but I couldn't agree more that we're going to see a Moore's Law kind of effect due to better use of data in health care.

Scanadu is far from alone in the field, of course.  We've had at home pregnancy tests for years, and the first home HIV test kit has just gone on sale in the UK.  The home tests aren't limited to pregnancy or HIV, of course.  I've written before about Theranos and Diagnostics for All, for example, who are both making a broad-scale testing from home a reality.

Blood draws have been a limitation for home testing, but Tasso Inc. now has a device that eliminates the need for needles, making it easier for consumers to draw blood themselves. Tasso's device still requires the consumer to mail the sample off for analysis, but I'm willing to bet it's only a matter of time before someone -- hello, Scanadu! -- figures out how to analyze the sample immediately or wirelessly transmit the data.

Why go to a lab for testing when you can do it at home?

We've already got portable ultrasound devices and may soon have portable MRIs, yet we keep sending people to imaging centers.  Maybe we should be sending the devices to the patient, not vice-versa.  One of these days these kinds of devices may be cheap enough to sell directly to consumers, with the results again interpreted real-time or at least sent wirelessly.

Looking further out, a professor at Leigh University has developed what he believes will become an at-home test for cancer.  Why not?  Researchers at UCLA have just rolled out a device that "can turn any smartphone into a DNA-scanning fluorescent microscope."

I suspect we're not going to go back to having surgeries at home, but it's hard to see what other services are necessarily off the list.

The good folks at Scripps Health recently issued a thought piece on the "emerging field of mobile health," reviewing its progress, opportunities, and key challenges.  I was struck by one comment in particular:
Too often, studies of mHealth technology have been designed to answer the question “How can ‘these technologies’ fit into existing systems of care?” Instead, the more appropriate question is “How can systems of care be altered to best take advantage of ‘these technologies’?”
I.e., we need to be moving past the current exploratory attitude of "what can be done at home?" to a more aggressive "what can't be done at home?" (or, if you are a glass half-empty kind of person, "what shouldn't be done at home?").

Every time I see hospital construction -- and I see it often -- I think, well, there are resources not being used to keep people at home.  Maybe hospitals are the wrong organizations to be trying Hospital at Home.

In a prior post, I argued that we weren't going to really change how our health care system is structured until hospitals and physicians start looking at each admission as a failure, analyzing what could have been done, when, and how, in order to keep that person healthy and/or at home.  We're not anywhere near there yet.

I've also argued before that the breakthrough emphasis in health care may not be value, or even quality, but rather consumer convenience.  Healthcare facilities can and certainly should become more convenient, but it's hard to beat care at home for convenience.

Not all care will ever be able to be done at home, or even in the community, but those situations should be our treatment choices of last resort, not our default options.


  1. I completely agree that care at home should be the goal of healthcare. It's cheap, convenient, and what patients want. What's nice is that science can finally deliver it. Clinical genomics, the science of what genes cause disease, allows prediction of who'll get which horrible disease, raising the hope that it can be delayed, if not prevented altogether. The patient gets to stay at home. Home also turns out to be the nicest place to die, where people have died for all previous centuries until the past half-century or so. Just staying at home would halve the cost of healthcare, and double patient satisfaction.

  2. I completely agree. Technology has changed the way we live; we go to school on line, do research, shop and communicate on line all done in our homes or offices. Health care costs can be reduced dramatically though home care. House calls should not be a thing of the past. It can have a major impact in lowering costs by avoiding unnecessary ER visits and readmissions! But Medicare has serious catching up to do to allow providers to bill for the service. Currently, the only allowable house call visit is for house bound patients with two or more chronic conditions.

  3. Not just the germs! My 93-year old mother just had her 3rd admission in 7 months at the same hospital for seizures. Potentially lethal drug overdoses occurred each time. 'Standard Protocol' at this hospital does not include checking Keppra level, so the busy hospitalists (who hadn't seen her since May when they overdosed her and sent her home without realizing it) guessed again at dosing. Without realizing, doubled her dose without checking her ALF records or calling her outside physicians. After discharge, she had a very adverse effect (again), and was readmitted next day. They guessed it was because her Keppra dose was too low. Wouldn't check Keppra level (not standard protocol), wouldn't listen to the family that she'd been overdosed and came within inches of ordering an elevated amount of another med. "Standard Protocol" too often means one-size-fits-all care. The cost of all this is way, way more than just dollars.