Imagine that you live in Kansas, far from the bustling world of large hospitals, world-class doctors, and instant health care. Besides yourself (a nurse), there is a doctor and another nurse. In this neck of the woods, most patients are more concerned with the health of their crops and livestock than with their own.
One day, you manage to wrangle a farmer into your exam room and give a quick listen over his heart. You pause, furrowing your brow. Something doesn’t sound quite right, but you aren’t sure what it is. The doctor, for all her training, knows it is a murmur, but is unsure if the sound warrants a trip to the nearest hospital or if it was there before. If it is new, then a trip is required, but your farmer patient doesn’t want to be bothered. What do you do?
This is where the technology of telemedicine steps in to help determine what the heart sound is, if it has been there before, and if the patient is in danger. Telemedicine has been around for a long time, but most health care providers don’t understand it. It is far more than a patient and a doctor chatting over Skype.
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In fact, those heart sounds you are hearing can be amplified, recorded, and transmitted through the use of an emerging technology—the electronic stethoscope.
“With the advent of applications and HIPAA compliant mechanisms, we have the ability to listen to heart sounds over long distances,” states Ami Bhatt, MD, FACC, director of the adult congenital heart disease program at Massachusetts General Hospital and an assistant professor of medicine at Harvard Medical School. This is an emerging technology, however, and it hasn’t quite been used in this way just yet.
“As the technology emerges, our first steps are to set up systems to use these devices in providing remote health care in a controlled environment where we can see if they help improve patient care,” Bhatt continues.
Weighing the Pros and Cons
Privacy is a large issue with the use of electronic stethoscopes in health care. Arvind Badrinarayanan, BSc, BVSc & AH, a veterinarian entrepreneur in India and founder of MUSE Inc., a medical device start-up company, is working on a low-cost electronic stethoscope. “One of the biggest concerns is encryption,” says Badrinarayanan of the privacy issues. “We are working heavily on that. One of the main features of our devices is that there is no way that the person can identify the patient. All of the identifying information is stripped off the file. The only one who has access to the data is the one who uploaded it themselves.”
Ami Bhatt, MD, FACC
How would this technology increase the health of the patient, though? “There are two ways telemedicine is conducted,” explains Bhatt. “One way is synchronous where the patient and provider are on the screen at one time. There is also asynchronous, in which the patient fills out a checklist or interview and it is sent to the doctor.” The use of electronic stethoscopes to crowdsource diagnoses would be more in line with the asynchronous type of telemedicine.
Electronic stethoscopes have other applications in addition to sending files to other doctors. For instance, the electronic medical record could benefit from sound files. “For our own purposes, we could record heart sounds one year and follow up next year with the recorded information. Recorded sounds in the medical record can give a comparison to what someone heard last time,” Bhatt explains. This would help a provider better diagnose changes and can help multiple providers of the same patient compare current sounds to previous ones.
Analytics are another way this technology can help patients. “We will be able to analyze heart sounds and compare them to known diagnoses, or severity of a diagnosis,” explains Bhatt. “For instance, this sound I heard is comparable with mild disease while this one is heard with more severe disease. Will every caregiver who sees a patient at intervals always catch progression of disease? We may rely on costly tests to tell us that. If I can use analytics from sound files, I may be able to catch that disease earlier and start treatment sooner. It is a far less expensive way to figure out when the disease is progressing.”
Overcoming the Barriers
Besides the privacy issue, this technology is not catching on, and that is primarily due to the price. Electronic stethoscopes are usually out of the price point for some providers, making them relatively rare in the care setting. This is especially true of rural areas that may not have the funds for such equipment—though they are the ones who would benefit most from the telemedicine technology.
Badrinarayanan saw this problem and decided to help make an electronic stethoscope that is more affordable for those who live in rural areas. “One of the many things we are doing is changing the way the products are developed, “ he says. “Most electronic stethoscopes are created in large research facilities. We use rural makerspaces, which are low-cost schools. These grassroots production hubs bring innovations to less-served rural areas. Practitioners and others can go and learn there. We can have the rural people do it themselves, and discover what the best ways are to solve their needs. In this way, we can decrease the cost of electronic stethoscopes for rural health care providers.”
“The ideology is that today’s digital stethoscopes are centered on cardiologists or high-end professional physicians,” says Badrinarayanan. “No medical device companies think about others who could use them. GE came out with pocket ultrasound, but the going rate is out of budget of the average physician. For these devices to have an impact, they must be accessible. We need to create a device that caters to the bottom of the pyramid.”
In the end, electronic stethoscopes, crowdsourcing diagnoses, and the use of recorded media are the wave of the future, but they aren’t quite here yet. Many practitioners worry about the privacy issue, and this is likely the main cause for reluctance to using the equipment. Convincing practitioners that this technology will be helpful to the patient is another hurdle that has yet to be crossed, and the staggering cost of the devices keep them out of the hands of the people who could use them most.
What is the future for telemedicine and the use of “smart” devices? Bhatt has a few ideas: “The idea of having a telemedicine cart is what we are working on. This would integrate both the ability to communicate with a provider in another hospital and assess recordings. We can have a blood pressure cuff and a stethoscope on the cart so that we can use them to let the other provider hear them. This is just one potential way that the technology will integrate.”
Until the technology and devices are accepted by mainstream medicine, these wonders will stay on the sideline. However, technology continues to encroach upon health care, and it is only a matter of time before electronic sound files are part of the medical record, heart sound diagnoses are crowdsourced, and electronic stethoscopes are a commonplace tool in the hands of the rural and urban provider.
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