Some five million plus years after humans wandered from the evolutionary Garden of Eden, Alexander Graham Bell gifted us with the telephone. There is an argument that the telephone was a modern day apple, and that mankind hasn’t been right since.
Not so long ago, Whitehall 9-4545 was an important telephone number in New Orleans. With Sherlockian skills, legendary operators at Doctors Exchange had a special knack for finding any physician on their rolls. When I started practice in the late 1970s, Miss Rita, one of the best, knew the location of “my doctors” most any time day or night.
Folks had more regular schedules back then. Miss Rita had back numbers for all the important restaurants and clubs in town. If someone ate lunch every Sunday at The New Orleans Country Club, she could find him (they were mostly male back then). She even had telephone numbers of girlfriends.
Medical communications changed with the introduction of the beeper. For years a dinging beeper signaled some sort of urgency, if not emergency. The beeping beeper begat the verbal beeper that begat the digital beeper that begat the cell phone.
The now omnipresence of the cell phone changed the tide of the doctor/patient relationship. Now, it’s the physician who’s often interrupted when some silly tune or whistle signals an incoming phone call for a patient under examination. Nine times out of 10, patients answer these calls with stock phrases such as “I’m with the doctor and can’t talk now” but keep on talking anyway.
But tides continue to change and now we have the smartphone. The medical electronic gods looked at the smartphone and declared that it is good. But good for what? It is time to learn from the emerging generation of physicians.
Last December Will Harris, a senior LSU medical student, took a general practice elective in my office. Harris was raised in Atlanta by a native New Orleanian mother. He has fond memories of summer visits with his grandfather Lyle Carriere, a bon vivant character if there ever was one. And in answer to that always-asked question about local bons vivants, the answer was Imre Szalai. The question wasn’t where had your grandfather gone to school, it was who had been his waiter at Galatoire’s.
Between hearing new tales about his grandfather from some of my older patients, Harris told me about a local New Orleans physician who’s making heart magic with smartphones.
Young Harris interviewed Dr. Richard Milani, vice chairman of cardiology and smartphone advocate. His answers were extensively edited for clarity and brevity.
Smartphones and Watches to Look After Your Heart
Q: February is heart month. When I Google “heart apps” I get over 170,000,000 hits. As Chief Clinical Transformation Officer at Ochsner, do you have a few favorites? Milani: Some apps simply let you learn more about a specific disease. Fooducate is a popular one. You use your smartphone to scan UPC codes and each scanned food item gets a grade from A to D based on calories, sodium and other parameters. Another is specific for women’s health. Others let you learn, track your own data and become engaged to improve your health status. We created the O Bar two years ago to help sort the wheat from the chaff.
Q: What’s the “O Bar” all about? Milani: Most persons with chronic diseases want to learn more and do more things on their own. O Bar is like a storefront at our clinic with a half a dozen iPads mounted on stands for patients interested in being more self-reliant. The idea is similar to Apple’s Genius Bar. It’s staffed by an IT specialist who answers questions, shows quick tutorials and helps with downloading various apps we recommend.
Q: What does remote healthcare monitoring involve? Milani: Wireless BP cuffs, blood sugar devices and scales to provide patient generated information for the medical record are examples. Instead of getting two, three or four data points a year, we can get several hundred.
Q: Tell us about your hypertension study. Milani: Patients with uncontrolled blood pressure receive wireless Bluetooth cuffs that hook up to their smartphones. We prefer three to four home or work blood pressure determinations a week, and ask for no less than once a week. Medications are adjusted as needed based on an established protocol. Both patients and their physicians get monthly reports. The program also issues individualized tips, education and engagements to improve blood pressure through diet and other health parameters.
Q: How do you know that home BP devices are really accurate? Milani: We’re only looking at FDA approved devices, and we double check readings in the office to make sure the home devices are being used correctly.
Q: And your results? Milani: So far about 70 percent of those using the Bluetooth cuffs become controlled in only three to four months. This is a six-fold increase compared to what we were seeing before. As folks become more involved with their health, there’s also an increase in both patient and physician satisfaction associated with our study.
Q: What are some of the future possibilities of this technology and are there any about which you’re particularly excited? Milani: Our heart failure program is currently working very well in reducing hospital readmissions. We will be rolling out a COPD/asthma program next year.
Q: What about technophobes? Milani: You may have an uncle or a grandfather out there who says “I don’t want to monkey with all that.” These are the people we can probably help the most since they’re interested, they have chronic disease and yet they’re left out in the cold. That’s why we make it easy for folks to find the answers to common questions at no charge using the O Bar as a model. We keep a curated set of apps by subject matter. We provide a “genius” behind the bar who helps you download the apps and show how they work.
Q: And the Apple Watch? Milani: We have a subset of patients using the Apple Watch within the hypertension program. This is a separate study, but the Apple Watch isn’t necessary for the garden-variety hypertension study I’m doing.
Q: Tell me about your smartphone. How often should a model be updated? Milani: I have an iPhone 6. I don’t have any recommendations for patients in terms of how often they should be updating their model, but it’s always good to have the latest software upgrade. Whenever they push an upgrade out, you want to have that. You don’t have to be on the latest and greatest device though, that’s for sure.
Q: Do you keep your smartphone on when you’re seeing patients? What about when you’re home and at night? Milani: I never
turn it off.
Q: Do any of your patients have your cell phone number so they can more easily contact you directly? Milani: Yes.
Q: What do you do when you are seeing a patient and their smartphone goes off? Milani: I don’t decompensate when someone’s phone goes off; they put it on silent or whatever else they may do and we continue the conversation.
Q: And finally, the name of your Galatoire’s waiter? Milani: I have to say I don’t frequent Galatoire’s regularly, so I don’t have a favorite waiter. I do like the restaurant, however.
Masked and white coat hypertension
White coat hypertension is an old concept used to describe blood pressure spikes in the physician’s office, yet normal blood pressure when checked at home or the corner drugstore. The cause is attributed to nervousness or anxiety generated by visits to the doctor’s office.
Masked hypertension is just the opposite. Blood pressure is normal in the healthcare setting but elevated at home, office or other times of the day. Masked hypertension is likely related to increased home- or work-related stresses.
Using such ambulatory and automated devices to record blood pressures outside the healthcare setting is a technique long promoted by Dr. Tom Giles, Past President of the American Society of Hypertension (see New Orleans Magazine, Nov. 2015).
The Dallas Heart Study followed 3,000 randomly selected Dallas residents recording blood pressures at clinic visits and with intermittent use of an automatic cuff worn night and day, at home and work. The recently released Dallas data showed that masked hypertension was much more common than previously reported. Only three percent of the participants in the Dallas study had white coat hypertension compared to 18 percent for masked hypertension.
Over the nine years of the study persons with either white coat or masked hypertension had more cardiac events than the persons with normal blood pressure. “Cardiac event” is a catchall phase to include such maladies as heart attacks, strokes, congestive heart failure, atrial fibrillation, chest pain workups and heart surgery.
Bottom line: Evolving data indicate fewer heart attacks, strokes and congestive heart failure problems when persons with white coat and masked hypertension are on blood pressure reducing medications.
