In this interview, we talk with Alexis Beatty, M.D. Dr. Beatty is currently working to improve use of cardiology through the use of technology facilitated approaches at the VA Puget Sound Healthcare System and University of Washington in Seattle. She studied Biomedical Engineering as an undergraduate, received her medical degree from Duke University, trained in internal medicine at Massachusetts General Hospital and achieved a Masters Degree in Clinical Research while completing her fellowship in cardiology at UCSF. She approaches her work from a cardiologist-researcher’s perspective, drawing from her biomedical engineering background for problem solving through technology-based solutions.

As part of this interview, we discuss the role of technology in cardiology and cardiac rehabilitation centers, how mobile technology can be a platform for facilitating home-based intervention and lifestyle modification, and how software design for intervention needs an increased focus on patient-centered approaches.

MA: So, Dr. Beatty, how do you see technology working in cardiology today, cardiac rehab in particular?

AB: Right now, there’s not a whole lot of technology working in cardiology and cardiac rehabilitation for mobile technology. In terms of things that we’re actually giving to our patients to take home and use on a regular everyday basis, it’s limited. There are a lot of consumer products out there that I see patients using, apps and devices that count their steps, things like that. I also know that a lot of those consumer products haven’t really been tested, and some of the data that’s out there needs to be coupled with other healthcare or behavioral health intervention pieces in order to produce some benefit.

There have been some research studies on using mobile technology for secondary prevention, for treating people who already have heart disease. Studies like the Text-Me study in Australia where they did text messaging and showed improved health outcomes for people. Another study out of Australia is Dr. Varnfield’s study that used a mobile app to deliver cardiac rehabilitation at home. I think those studies show a lot of promise for how interventions can be successful on a mobile platform and ways to design intervention that can be successful. Particularly, I think it’s good that Dr. Varnfield’s study looked at the use of the mobile apps, sort of an integration with the home-based cardiac rehab program.

I think that’s how we’ll see a lot of technology being used in the future. People using it along with their healthcare providers. We still have a lot of work to do to figure out how to integrate these interventions into clinical care, and then to figure out if they really make a difference long-term because I don’t think we know that either.

MA: I see, so what you’re saying is that intervention comes first and the technology second. How do you see technology helping a home-based intervention? How do you want your technology or tools to help you achieve in that intervention?

AB: The intervention is the main thing and the technology is a tool within the intervention that makes it easier or better for people. I think those are kind of the things that I focus on. Is the technology something that’s making it easier to accomplish what you want to be doing? Then, does the technology add something on top of the intervention that actually makes the intervention more effective. Within that, I think there are a few things.

MA: Sounds like there are quite a lot of uses. Increased communication, access to educational resources, and better sensing of a person’s daily activities and lifestyle.

AB: The doctor’s only with me for a few hours a year, but my device is in my pocket most of the time.

MA: Yes, there is great potential and a little comfort in knowing that a patient has a device by their side, year round. A device that can communicate with and amplify the abilities of their doctor. So earlier, you said that your patients bring in a ton of data and you don’t know what to do with it. As a practitioner, what data do you want from your patient’s smartphones that would help you understand or treat them better from their smartphones?

AB: Well we don’t really know what is important through these streams of data yet and I think we should also be asking the patient what’s important to them. I think the answers that you get from a provider will be different from the answers that you get from the patients.

Some things that I presume the patients are interested in are things like symptoms, how they’re feeling, symptoms related both to their heart disease and mental health, their overall well-being. That’s one thing.

The other is functional status, you know, can people do the things that they want to be doing. That’s very important. We view that as important as providers, as well, because we know that functional outcomes are associated with a lot of things.

Then, as a provider, I’m used to tracking how much physical activity are you actually doing. How much in terms of the duration, frequency, and intensity? In a lot of ways it matters less what the exact activity is as long as those other three things add up. Whether it is walking, or swimming, or running, as long as you’re doing something that’s of sufficient intensity for enough time, that’s good enough.

I also care about things like blood pressure and heart rate because we know that blood pressure, at least, is an important risk factor and heart rate can be a sign of things going well or things going not well.

MA: That’s an interesting point you brought up that what the patient may want to know for their own understanding may be different from what you want to know.

AB: Yes, people come in and show me their blood pressure, and sometimes I think that’s because they’re very focused on it and they want to know what it is, and other times it may be that they feel that I think it’s important. I’m not sure we have too many things that are truly geared towards what the patients think is important.

MA: How do you feel about the accuracy of these devices. Is accuracy important? Is consistency more important than accuracy? What do you think needs to happen for devices to be seriously considered for clinical care?

AB: I think that for the most part, engineers are doing a great job of making the devices at least reasonably accurate. I think as long as a lot of care has gone into developing things such that they are accurate, it’s not a huge concern for me. There should be some transparency in terms of people knowing what the accuracy of the method is and as long as you have that available, it’s okay.

However, if they are being used as medical devices. There do have to be standards for what their accuracy is. I think right now, wearables and other such things that aren’t being used as medical devices do not have to meet those standards as long as they’re sort of more informational purposes. When data starts being used to drive medical care there will need to be a high degree of accuracy and regulation.

MA: I’ve heard that an app is released roughly every 5 seconds. In my personal experience, it feels as if legislation and hospital policy do not evolve as rapidly. How do you think legislation and hospital policies can help foster innovation while safeguarding patient safety and privacy? What do you think, in your experience, should be the right balance there?

AB: Well that’s a difficult challenge because I do think that we move pretty slowly in terms of policy and healthcare systems adopting new things. That’s partly people being appropriately cautious because we do not want to do harm. It’s also part of our culture and the way a lot of things are setup. I do think that some policy changes are happening which will allow for a little more flexibility in how people apply these technologies. One is the fact that you can get paid for telephone and telehealth visits. The VA is a great example of the system, it employs a lot of telehealth and gives its provider credit for providing that telehealth like it’s a face-to-face visit. Setting things up so that they support new technology is very important, even if it is kind of treated in a lot of ways just like a different version of a traditional encounter.

Certainly, that’s one thing that’s adoptive of new technologies and new versions and new things like that, I think it highlights how important it is to consider the overall intervention rather than the specific version of the technology when you’re implementing things because the technology is going to change. Knowing that upfront and thinking about that in everything that you do and making your system adaptable is very important.

MA: Yes, like you said, intervention comes first. It’s all about how you prove intervention then technology or anything new that comes up. On that trend, I think you’re right in that systems where they’re both a payer and the providers, systems like the VA and Kaiser, tend to adopt the telehealth technology faster. In fact, the VA’s a leader in telehealth adoption. In regards to their adoption of telehealth and bundles, or value-based care, what is your prognosis on these kinds of approaches and are there caveats you have to keep in mind regarding patient experience so we don’t jump in so fast?

AB: Right, you’re talking about value-based care and the best example that we’re going to see coming up as the Medicare Innovations program for myocardial infarction and coronary bypass surgery. I think their goal is to provide value-based care and reduce hospitalizations, and they’re doing that through the bundled payments and also through cardiac rehab incentives. I think it does give hospitals and health systems a little bit more leeway to experiment with non-traditional ways of providing care and with non-traditional ways of providing cardiac rehab.

It’s unclear to me whether people are really going to be looking to mobile technology or telehealth for improving their value-based care under these programs. I think part of the reason why these Medicare Innovation programs exist is to spur some innovation in these areas and to try to figure out what might work. I hope that what comes out of this is that we have a little bit more evidence to tell us what we should be doing to improve value-based care.

MA: I think our time is running short so I will end with this question. If there was one change you could make in cardiac rehab or cardiovascular disease treatment on mobile apps today, what would it be?

AB: I think the biggest thing is that I want cardiac rehab to be more accessible. The traditional approach of center-based cardiac rehab, even though the programs themselves are very focused on individual assessment, goal setting and helping the individual, is very not focused on the individual in terms of structure because we basically only offer the traditional cardiac rehab option.

I think the biggest change needed is to be creating more ways to provide cardiac rehab that fully address the rest of the individual needs outside of the traditional center-based program. That includes things like home-based cardiac rehab programs and the use of mobile technology, both for facilitating home-based cardiac rehabilitation and for just promotion of healthy behaviors in general. We need to make sure that we reach more people with cardiac rehab.

MA: Great. I hope that it gets happening too because I think that the lack of access is what’s holding it back from proving it’s full potential. I think a lot of folks are looking for ways to solve that, so that’s great.

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