Medicine Is Not One Size Fits All

Conference focuses on individualized healthcare

1 July 2010

Everyone is unique. Medically speaking, that can be a problem.

What makes you sick might have no effect on your neighbor. Even if it does, a treatment that works for one might not work for both. A standard prescription dose could be too much for you but too little for someone else. Meanwhile, so-called normal temperature and blood pressure readings actually might be hiding signs of a serious abnormality. Such variations can stem from a person’s genetics, lifestyle, diet, gender, age, or environment.

Tailoring health care to patient differences used to rely on trial and error, family history, and doctors’ intuition. These days, it increasingly depends on technology. That’s why the American Medical Association and the IEEE Engineering in Medicine and Biology Society joined forces in March to sponsor the first AMA-IEEE Conference on Medical Technology on Individualized Healthcare, held in Washington, D.C.

Engineers listened to what doctors need in individualized systems, what holes current technology might fill, and what problems it might solve. Doctors learned from engineers what solutions might be feasible.

The best-known individualizing technology is genomic testing. Scientists have sequenced the human genome and found gene variations that cause or predispose some people to certain diseases, affect patients’ response to medication, and are the source of environmental sensitivities. Transplant surgeons use genomics to determine a patient’s risk of rejection. Drug makers are investigating genomic markers to lower the expense and risk of clinical trials. There’s even a low-cost home-testing kit that will identify many genetic risks and the predisposition to adverse affects from several drugs. But most diseases, and most factors affecting the efficacy of therapies and harmful reactions to them, still have no known genomic link.

Genomics is just one component of individualized health care, according to Dr. Paolo Bonato, an IEEE senior member and the conference’s program chair. Others include connected health (telemedicine), point-of-care technology, and electronic health-care records. Dr. Bonato is assistant professor of physical medicine and rehabilitation at Harvard Medical School’s Spaulding Rehabilitation Hospital in Boston.

So-called normal readings for blood pressure, blood glucose levels, and other parameters are merely averages. Most blood pressure measurements are taken infrequently, perhaps annually, in doctor’s offices. Such readings are often high, from patients running late, coming in early, or being anxious about what an exam will uncover. And blood pressure varies with gender (lower for women) and with the time of day.

“If we’re serious about preventing hypertension, we need to know what your norm is,” Bonato says. “If it has typically been 90 over 70 in the past but has been rising, that’s a concern even before it reaches the statistical norm of 120 over 80. If we know it’s rising, we can intervene early.”

“Yearly physical exams or episodic evaluations are useless,” says Dr. Jay Sanders, president and CEO of the Global Telemedicine Group, in McLean, Va., and adjunct professor of medicine at Johns Hopkins University in Baltimore, one of the conference speakers. “The best-case scenario is continuous monitoring.”

Sanders, an IEEE member, predicts an imminent telemedicine explosion in the form of body-worn sensors attached like Band-Aids or in clothing, then embedded sensors, and then nanosensors that will circulate in the bloodstream and continuously monitor body temperature, blood oxygen, pulse rate, heart rhythm, blood pressure, and glucose, feeding the data to a smartphone for transmission and processing.

Already there are simple wristwatch pulse sensors for smartphones, applications that convert an iPhone’s camera to a microscope, and a device that takes EKG readings when a patient grasps its rim. Coming soon are health-care smartphones with laptoplike computing capabilities. The phones not only will acquire the data streaming from wearable, embedded, and circulating sensors, Sanders says, “but will also analyze it, compare it with the patient’s normative values and send alerts to the patient and health-care providers when readings go out of range.”

Data from medical devices that live with you as you go through daily life will be more useful than health data coming “only from snapshots in time in the doctor's office or in the lab,” according to speaker Jan Oldenburg, senior practice leader at Kaiser Permanente Internet Services Group of Oakland, Calif.

Monitoring can help change behavior, she says: “It could show me that I’m getting too little exercise or that my blood pressure is out of range too much, and how exercise affects my blood sugar level. My doctor won’t have to rely on how accurately I recorded this information.”

Monitors worn all the time, Bonato says, also will be able to help doctors “detect sporadic events such as cardiac arrhythmias. And they can tell at once when chronic conditions become acute and immediate intervention is required.”

Other instruments will become important as well, experts predict. In doctors’ offices and even in the home, instruments such as ultrasound scanners, microfluidics analyzers that test a single drop of blood, and other devices can make critical information available quickly and inexpensively. With them, Bonato says, “we can prevent acute situations from occurring and can detect and handle situations that require intervention. This helps avoid hospitalization.”

The U.S. government has proposed that hospitals have electronic patient medical records integrated into their operations by 2015. The records could help researchers correlate patients’ normative vital signs, diagnoses, useful therapies, and adverse reactions in new ways. The availability of such patient databases also should make drug trials faster, safer, and less expensive. And once electronic records are set up to capture and use genomic info, for example, says Dr. Greg Feero—a conference speaker and a special advisor to the director of the National Human Genome Research Institute, in Bethesda, Md.—it will be possible to check a patient’s genome for, say, colon cancer risk, and to check back again when new ways of analyzing that risk arise.

Electronic records can help minimize errors. Prescriptions, for example, may be checked by pharmacists or physicians against a patient’s records to see whether other medications being taken might conflict, or whether the person is allergic to certain drugs. Patients could access their records to correct inadvertent errors or to add potentially significant details they might forget to mention during an office visit.

For chronic conditions, physicians will be able to learn what therapies have worked or failed, and also detect changes to a patient’s health over time, even if the person has switched doctors, experts say. But patients’ access to their own medical records can be equally important.

“People mishear about 50 percent of what the doctor says and understand only about half of what they do hear,” Oldenburg says. “Making records accessible to patients helps, if they’re understandable.”

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