Health & Wellness Apps For Patients

The number of apps over the past 5 years has exploded for both healthcare professionals and patients, alike. We are talking exponential growth. A recent count of the iTunes app store identified more than 13,000 healthcare and "wellness" apps! To help control this influx of apps the FDA has actually inserted itself and defined a difference between a "health" app and a "wellness" app.

A health app is categorized by the FDA as mobile software that diagnoses, tracks or treats disease.

A wellness app is mobile software that enhances or tracks the overall health of the user.

That said, there is a ton of crossover between the 2 classes e.g. a calorie counter that can then make recommendations about how to adjust your intake or a BP tracker that alerts you to call your physician when there are too many consecutive high numbers.

A relatively quick and easy way to identify successful patient apps is to check out which patient-centered apps have the most downloads in the iTunes Store and peruse the reviews written by patients (often the younger set). Here are some apps that I feel have transcended the niche medical category and gone into the widely used & useful category:

1. WebMD - This is the one of the major categories of patient apps - EDUCATION (the other categories would be DATA RECORDING/TRACKING, and the last would be MANAGEMENT). It's easy to use, full of reliable information, has a trusted brand, and offers side tools like a pill identifier. Oh yeah, and it's FREE and available for iPhone and Androids.

2. iTriage - A cool and rather progressive app that allows patients to find the nearest ERs and can often provide estimated waiting times (altho the accuracy on that is questionable). It also serves as a crude diagnostic tool when you provide symptoms and gives a ton of reference information on medications, procedures, conditions etc. It is FREE and available for both platforms.

3. BP Monitor or BP Tracker by HeartWise - Probably the most success I've had, from a personal standpoint, in getting my patients to use apps. While there are BP cuffs available at Walgreens and the Apple Store (http://store.apple.com/us/product/HB134ZM/A/ihealth-wireless-blood-pressure-monitor) that hook into the iPhone directly or wirelessly, the most common BP apps just serve as a substitute for the yellow legal pad on which most people record their daily reading. The benefit of these BP trackers is that they can be exported rather easily in graphic or tabulr form to the doctor by email or printed out in a presentable fashion. My patients that use them, love them.

4. Glucose Companion or one of the numerous other glucose/calorie tracking apps. There are several and they serve a similar purpose to the HTN apps listed above. Recently, apps like WellDoc are attempting to integrate their data with existing EHRs - and have been successful, improving the management of patients while physically seeing them less!

5. Gazelle - For many of us specialists, keeping track of patients labs' are a chronic issue and patients are often inconvenienced by the fact that we dont do labs in our office and often dont get copies of their recent bloodwork. This app by Quest Diagnostics allows pts to make appointments online and track their lab data and keep it on their phone!!!

6. Pill Reminder - Medication adherence has been identified by the mobile medical community as one of the low hanging fruits that we can address using these devices. This app by Drugs.com attempts to achieve success in this space. Logically, it sends reminders when to take meds as well as when you might need a refill and provides a drug reference geared towards patients.

7. My Fitness Pal or Calorie Counter - There are numerous apps in this space and I havent had time to sort thru all of them but they all attempt to acheive the same goal - provide the patient with info so that they may make healthful changes. Some even make recommendations. They vary is their ease of use and some will interface with a wearable device (FitBit or Nike product) that count your steps and monitor your breathing while you sleep giving you biofeedback info as well.

8. Google app - Still and likely always, the most common resource for health information. The results sometimes may be muddled but overall it often serves as a wonderful resource for information.

9. ZocDoc - For patients who are likely more progressive and do everything online. This app allows patients to find doctors in their area, put in their insurance info, and actually book an appointment online.

R.I.P. James "Tony" Gandolfini - What Can We Learn?

When I was living in Chicago, missing the brash Jersey attitudes and Italian delicatessens of my youth, The Sopranos provided me with a sixty minute journey back home every week. Whoever watched with us, as we hung on every word, would also be forced to endure my vocal alerts for every North Jersey sighting embedded in a TV drama that seemed so real. The Lincoln Tunnel exit, Route 3, Bloomfield Avenue, lots of cured meats and wet muzz - things that were unique to my home - Jersey.

The viewing of The Sopranos began to take on an event-like atmosphere, preceded by numerous pots on the stove, sausages and meat balls, gravy simmering, wine pouring, friends talking and congregating - until, that is, the intro began with its heavy baseline and Tony, arm out the window, cigar in hand, making all of us feel lucky to know him, and to not be on his bad side. The good bad guy.

The controversial fade-to-black finale without closure now takes on such a more profound tone - since we know what happens in real life. James Gandolfini's passing is sad for so many reasons - the term "untimely" hardly does it justice. The death of any young person - particularly from potentially preventable causes - is a tragedy. And events like this, because of their notoriety and widespread media coverage, have the opportunity to spur change.

 Gandolfini was such a young man at 51, leaving 2 young children and a wife behind; aborting a proud and accomplished acting career; and for those of us who hale from his home state of New Jersey, the former Rutgers grad's death cements his image in our minds as a small screen icon. Jersey has had so many famous residents (don't make me name them, 'cause I can) but none as "Jersey" as Gandolfini.

The fact that he was so famous/beloved and so young and didn't die of what so many young, famous people die of (addiction), makes the story so acutely interesting - not just in a Page 6 way, but more from a "what can I do to prevent that?" way.  The death of any young person is tragic and often engenders questions of how and why - yet the answers sometimes leaves us unsatisfied.

Objectively, Gandolfini was not the picture of health. He was likely technically obese and had a well-documented penchant for food and cigars - to the point that his last meal has been chronicled in every newspaper that reported his death - as if it had a direct relation to his sudden cardiac death. Which it very likely, did not. Would they have done that for a thinner man?

The fact is that out-of-hospital cardiac arrest occurs more than 380,000 every year in the United States alone - with the vast majority occurring inside the home. Many of those happen in people with no known heart disease. This is an incredibly strong argument for why ALL people should learn hands-only CPR - an unbelievably  simple skill that can literally make the difference between saving a life or watching someone die. This link will teach you all you need to know: http://www.heart.org/HEARTORG/CPRAndECC/HandsOnlyCPR/DemosandVideos/Demos-and-Videos_UCM_440561_Article.jsp.

 Less than one third of all cardiac arrest victims actually receive CPR - a shame when you can literally triple the likelihood of saving someone's life just by pushing on their chest to the tune of Staying Alive.

That said, how can you prevent a tragedy like this from happening to you or a family member? Knowing the obvious warning signs is  a good start: so, if you have chest discomfort that lasts more than a few minutes, or that goes away and recurs (particularly with exertional activity) - that's concerning and needs to be worked up by a doctor. Alternatively, some people may also develop left arm pain, jaw pain, nausea and/or diaphoresis (sweating) - equally concerning signs that merit a visit to your doc. Women and diabetics tend to present with somewhat atypical signs e.g. abdominal pain, back pain, shortness of breath. The take home message: if you are concerned with symptoms in or around your chest area and you have one or more of the risk factors described below: GO TO YOUR DOCTOR.

Once the event has occurred, damage has been done - so the real question is: who is at highest risk for having a cardiac arrest or heart attack at a young age? Contrary to popular opinion, early onset coronary disease has never been conclusively linked to a stressful job or life. In fact, it is more likely people's coping mechanisms (smoking, drinking, drugging, eating), triggered by their stress, that cause their cardiac events. Actual statistically proven risk factors for coronary artery disease include:

• Smoking
• High blood pressure
• Elevated cholesterol and/or triglycerides
• Family history in 1st degree relatives (father, mother, bro, sis) of CAD before 55 in males and 65 in females.
• Diabetes 
• Obesity

The above risk factors are vetted by numerous studies, but I will add one more that I feel likely contributes to a vast number of these cardiac embarrassments: lack of medical attention. Younger men in particular often veer away from medical attention despite the proverbial writing on the wall. They also tend to ignore symptoms that may herald an impending disaster. The fear of discovering something trumping the much less realistic seeming fear - that one may die from doing nothing. So, if you are one of these men (or women) - or live with one of them -  do not ignore your symptoms. Go see a doctor.

Cases like Gandolfini's and Tim Russert's death not too long ago, remind us that coronary disease and its sequelae can be devastating and without obvious preceding symptoms. In the interventional cardiology community we see these events fairly frequently, and most of them do not receive much fanfare. With the advent of so many new technologies and vastly improved treatment of heart attacks, we still are unable to save everyone. The key to better outcomes is better prevention.

Is Less Really More?

The smart folks at the American Board of Internal Medicine Foundation have published an additional 90 procedures (to the 45 that they listed last year) that they feel are overused and often times unnecessary. This is part of the Choosing Wisely initiative to encourage patients to ask more questions about the tests that they are having and the reasoning behind it.

Unfortunately, we have become a test-happy medical society in the US and the reasons for this are myriad. Firstly, old habits die hard. Doctors in a given specialty see similar diagnoses and have been doing the same testing routines for years. It is difficult to get physicians to change their diagnostic/therapeutic habits when they have been doing it with success for eons.

Secondly, medicine is a business. And for doctors, it has not been a very good one of late. Reimbursement rates for everything from office visits to echocardiograms have plummeted and physicians are not immune to the squeeze of earning less money for the same amount of effort. Already, we are beginning to hear murmurs of doctors objecting to answering phone calls in the middle of the night when they're not getting paid for it. This used to be part and parcel of being a "patient of the practice" but this old style of long, personal relationships with your physician is waning. Five years ago less than 10% of all cardiologists were employed by a hospital and as of 2012, more than 60% of US heart doctors have some formal business relationship with a hospital system. Healthcare providers are having to see more patients in less time and modalities like telemedicine, pharmacy consultations, outpatient phone calls and remote monitoring will become more and more important in the years to come.

Finally, many tests and procedures are done for fear that the doctor may miss something and pay a much steeper penalty than wasting a few health care dollars on a test. Most patients that come in to the ER with chest pain can very readily be diagnosed with a good history and physical. Heart attack symptoms can be tricky but there are some universal features that put patients at higher or lower risk. However, the fear of missing any diagnosis, no matter how unlikely prompts serial blood draws, CT scans, stress tests and increased length of stay. Attempts to lessen the threat of lawsuits and financial demise from medical management have been met with a great deal resistance and so doctors will consider doing CT angiograms of every young woman who presents to the ER with shortness of breath and happens to be taking oral contraceptives - even if they have a very low likelihood pulmonary embolus.

Initiatives like ChoosingWisely.org are a great start in changing the consensus opinion of how patients should be managed and allowing the doctors who choose not to over-test to fall back on educated and validated medical opinions confirming that sometimes a good history and physical in addition to carefully selected testing (or perhaps no testing at all) is the best thing that can be done.

If nothing else, a perusal of this list of overused and over-ordered tests can give you good reason to ask your physician more questions about exactly why they are ordering the test and what will change as a result of the outcome? Is the test safe, what are the risks? The ChoosingWisely website also has answers to specific questions like 'Do I need a Chest XRay before surgery?' and 'When do I need a stress test?' It is a very worthwhile stop on your Internet travels so give it a read and take more control of your medical care.

Catheterization from the Wrist Taking Over

Just recently, cardiac catheterization from the wrist, or transradial cardiac catheterization, was featured on the Dr. Oz show and immediately we were fielding questions about it in the office and reading about it on the blogs.

Now, even more impactful, was the recent recommendation from the European Society of Cardiology that the radial approach should be considered as the first-line access site:

“The radial approach for percutaneous coronary interventions (PCI) was developed 20 years ago and is used for more than 50% of procedures in France, Scandinavian countries, the UK, Spain and Italy. Despite the advantages of radial access some countries in Europe such as Germany use radial access for fewer than 10% of PCI….

“Evidence has accumulated in the literature showing the benefits of radial over femoral access for PCI including reduced bleeding and improved survival. In addition, the development of smaller and thinner devices has made the radial approach increasingly practical.”

For most of us in the interventional cardiology world, the radial approach has been slowly gaining traction over the past 5 years in the US. As of 2007, less than 2% of all coronary stent procedures were done from the wrist but in 2012, according to the National Cardiovascular Data Registry (NCDR) more than 11%  were done radial style.

Patient safety and comfort are always a concern to physicians and the radial approach has shown superiority to the femoral (groin) approach in both categories. In terms of safety, numerous studies have shown significantly less bleeding complications as compared with the femoral approach. This is in large part due to the fact that unlike the radial artery, which is bordered by bone and connective tissue, the femoral artery lies right next to a large caliber femoral vein and complications can be difficult to identify at first because of the large potential space for blood to go, i.e. the thigh or abdomen. Women are actually at higher risk of groin complications from cardiac cath and currently Dr. Safirstein is the Principle Investigator of SAFE-PCI, a multicenter, randomized control trial looking at the benefits of the radial approach in women, run in collaboration with more than 25 of the best coronary centers of excellence across the US.

Comparing comfort of the 2 techniques, it is not hard to see why patients have preferred radial more than 90% of the time. Cath from the wrist allows patients to sit up immediately after the procedure (even when a stent is placed) with a pressure dressing over the small puncture site on the wrist. The femoral approach demands anywhere from 4-8 hours of lying flat so as not to disrupt the clot that forms over the femoral puncture site. This becomes particularly relevant in patients who have back pain issues or cannot lie flat for any reason.

From a cost standpoint, less complications mean less money spent on follow-up imaging studies, blood products that might be required, consults with other specialists, and of course, length of stay. The radial approach has been shown to save both hospitals and patients money and time in the hospital.

Drs. Safirstein and Fusman both are proficient in radial cath and Dr. Safirstein served as the Director of Transradial Intervention at Morristown Medical Center. Later this year, he will be Course Director for the annual Mid-Atlantic Radial Symposium (MARS2013), hosting world-renowned experts who will educate both physicians and cath lab staff from NY/NJ/PA on everything transradial!