Participating more in your health examinations?

Your ankle has been hurting for a while, and today it hurts a lot. Not knowing why you are in pain is making you anxious. If you could x-ray it in your living room, and send it to someone to look at, would you? What if instead, you had chest pains or heart palpitations? If you could send a recording of your heart sounds to a doctor, would you?

Most people who feel unwell want answers right away. They want to be examined when they are symptomatic, but it is rare to get an appointment with a medical professional instantly. If there are follow up tests or consultations with specialists, it feels like it will take weeks or even months before  anyone is ready to start solving your problem. For most of us, it seems that health care doesn’t move forward until you are examined, and your diagnostic health information is actually recorded.  These tests initiate the process of evidence collection around which clinicians can rally and move towards a diagnosis to treat your ailment.  Many times, however, you feel like you are going in circles until the right clinician listens to your chest or looks at your x-ray or sees your symptoms firsthand.

Now consider if the nearest medical clinic that can provide you with diagnostic and ambulatory testing services is three hours away and understaffed. What if you must take time off work or have other responsibilities? Effectively coordinating the doctor, clinician, patient and testing equipment in the right place, at the right time now gets a lot harder.   This burden ultimately rests with the patient or a concerned family member, yet there are few if any options other than waiting for appointments just to get the ball rolling. Troublingly, 53 million people in North America live in areas that are considered medically underserved; globally the number is in the billions.  Not surprisingly, these populations are at higher risk of complications due to undiagnosed conditions like CVD, heart failure and COPD. According to the Institute of Health Metrics and Evaluation in Washington DC, these conditions are the root cause of most deaths in both rich and poor nations.

Over the past 18 months, medical visits in the USA that were initiated using a telehealth or telemedicine platform to connect patients with healthcare professionals have increased 38 times more than before the pandemic.[1] And approximately 40% of surveyed consumers stated that they will continue to use telehealth to access healthcare services. In Canada, a 2020 report on consumer attitudes for telemedicine indicated that nearly 70% of surveyed consumers believed that virtual healthcare would allow people to be more proactive about their health and the health of their family members.[2] These and other reports suggest that remote and virtual access to healthcare services will soon become a normal and possibly preferred way to access care. This trend begs the question as to whether virtual healthcare consultations can be made more meaningful (and even rewarding for the patient) by also incorporating some of the diagnostic testing you would normally need to travel to a clinic for.    

Rina Carlini is President and CEO of Optimal Innovation Group. Her company consults with medical technology innovators who are developing digital and mobile health solutions and delivering better access to healthcare services. She sees things changing in a big way:

Rina, do you think there is room for a more democratized approach to healthcare – one where the patient can contribute to the process by providing diagnostic data they gatherd at home?

“Yes, I think the process has always been inefficient, requiring people to wait a long time for care – hours, days, even several weeks for specialist care. For those who live in rural or remote communities, the inconvenience and inefficiencies become a more significant barrier. Giving patients the ability to initiate more of their own care from home (rather than the waiting room) is long overdue.  Thankfully, we now have the technology solutions that offer virtual, mobile access to healthcare services for people wherever they are.  To realize the full potential here, we also need proactive and equitable healthcare policies, funding and educational support. The payoff is a true democratic access to healthcare for everyone.    

Do you have first-hand experience you can share ?

“Yes, as do many people. My mother had complained of occasional heart palpitations and feeling lightheaded since her mid-40s. Now that she’s elderly and living alone, the frequency of these incidences has increased. She’s undergone testing at clinics and hospital centers using the typical diagnostic tests – ECG, BP, etc. – but none had ever revealed a conclusive sign of an underlying condition. These palpitations were short-lived when they happened in her home, and by the time she got medical attention in a clinic (typically 1-3 days later), they had often passed. The physicians thought it was “in her mind” and suggested that she see a psychiatrist; for her, this was both disheartening and patronizing. If only she had the tools and ability to record her sensation of heart palpitations right when they happened. Recently she was hospitalized, and the internist physician finally determined she was living with mild arrhythmia and was prone to atrial fibrillations. The diagnosis set her on the right course of care with medication to regulate her heart rhythms. She would have been spared years of stress and anxiety if we could have gotten here sooner.  

Today we have available a wide range of clinically-validated digital health tools and mobile apps that can empower patients to perform diagnostic health tests. My mother and many other people across the world should be able to access these apps. This is a way to empower people through recorded evidence of their ailment. The test data could be shared by the patient to their healthcare provider and circle of care.  That is digital health equity, and it makes democratized access to healthcare possible.”    

What if the patient, or their caregiver, had the option to initiate simple tests like recording heart and lung sounds, or an ECG, instead of having to wait for a primary care physician or nurse-practitioner to do it in a clinic? Could simple home-based diagnostic tests qualify as an auditable record of the patient’s medical evidence that will lead to a faster diagnosis? What if all this could be done without the need or cost of special equipment, using just a normal smart phone or tablet?

At Sparrow, we think this type of democratized access to clinical-quality virtual healthcare is both inevitable and necessary. There are 3.3 billion smartphones in the world.  What if there was a specialized app that transformed these into “smart stethoscopes” –  augmenting virtual care examinations for patients anywhere, anytime.  Technology solutions like this can be a true liberator for many people, including physicians and clinicians who want to deliver the best evidence-based care for their patients without the traditional barriers. It’s not about replacing gold-standard tests or diagnostic skills with new technology; it’s about offering millions of people a faster and easier way to get the ball rolling when it really matters.

By Mark Attila Opausky

[1] McKinsey Report: “Telehealth: A quarter-trillion-dollar post-COVID-19 reality?”;  O. BestsennyyG. GilbertA. Harris, and J. Rost, July 9, 2021.

[2] Environics, 2020; “Canadian Attitudes on Healthcare and Telemedicine.”

The Power of Sound

The sound of a functioning heart, vessels, and lungs contains a surprising amount of information about their structure and function. These sounds are often sufficient to make an accurate diagnosis and conduct informative clinical monitoring. But there has always been a problem. Not surprisingly, mastering the ability to analyze these sounds has traditionally been a complex, long-term process. Add to that, the problem of so called low-frequency sounds. Low-frequency sounds are thousands of time harder for humans to hear so our consciousness leans towards ignoring them. Some think this is evolutionary. Most things in nature that could harm humans (angry bears, volcanoes, other humans etc.) tended to make sounds at much higher frequencies so we are predisposed to focusing on those. Yet a number of important auscultative symptoms, such as gallop tones S3 and S4, mitral stenosis murmur, Still’s murmur and Austin Flint murmur are exclusively low-frequency and extremely hard to perceive. With the help of modern analysis, sound processing and artificial intelligence technologies, this traditional limitation no longer exists and so neither do the barriers to using biological sounds to accurately, quickly and inexpensively diagnose conditions.

Modern echocardiography produces high quality medical insights but is not a panacea. Like all measurements, it has limitations based on the fundamental nature of the information it is based on; namely the shape and related mechanical movement of structures. To be clear it is a very rich information source from which to mine insights. But from a technical perspective, biological sound data is arguably just as rich if not more potentially informative. All moving (dynamic) systems emit energy as sound. What makes sound so rich is that it has two fundamental components: (1) Frequency: e.g. low-frequency oscillations, as a component of hemodynamic murmurs, are caused by movement of large blood volumes, and the high-frequency oscillations by high-speed blood flows etc. and (2) Amplitude. Amplitude considered alongside frequency provides additional information about the power of the sound. Power is interesting because we can use it to assess the severity of certain conditions (like mitral regurgitation). Diagnosis based on ultrasound or other tests can actually miss this because the underlying signals they process lack this information.

We think chest sound data is extremely valuable and, as it happens, potentially easier to collect and analyze than echocardiography for instance. And early accurate diagnosis matters. Diseases such as infectious endocarditis can be detected by the presence of quiet cardiac noise at an early stage but in practice it is often detected only much later with echocardiography, when the disease has caused catastrophic damage and the chances of survival are diminished.

The Struggle for Patient Value

The focus for providers and payers is shifting in pursuit of better value for the money spent. As such, the concept of value-based healthcare (VBHC), tabled more than a decade ago, is now an official part of the conversation; albeit far from being a reality.

On the surface, it’s a devastatingly simple model centered on patient value. Where value increases by improving outcomes or, at the very least maintaining outcomes at a reduced cost.

Patient Value = Outcomes/Cost to achieve Outcomes

The central ethos here is that health and not the volume of treatment is the defining outcome for medicine. For the math to work, the value of health is defined in terms of survival years gained or some other relative net improvement. So to allow this to be measured, and therefore paid for, we need better measurements or some proxy for patient and health outcomes; this is far from simple.

It seems many of the obstacles standing in the way of doing VBHC at scale have to do with alignment on which outcomes to measure and how to measure them. This alignment needs to be present between the patient, provider, payer, and the industry. First steps have been taken in areas such as better individual patient-reported outcome measures (PROMs or ePROs). Increased focus on the patient and the uniqueness seems like what we should be going for here. But this can break down when you over personalize the outcomes to each type of condition or individual patient. There also remains the issue that you need to deploy the right care in the right place as well as coordinating care where multiple conditions are present to avoid undesirable health inequalities and unnecessary costs. But the system fails economically if we add complexity while simultaneously trying to improve precision. Given these constraints, we still need leadership to realize a unifying, common set of value criteria and outcomes.

Data helps here a lot. The growing volume of available health data, both structured and unstructured, and the maturation of policies and infrastructure to allow for the pooling of that data will give us a resource to try to arrive at this alignment about outcomes. Simultaneously, we now have better understood and more efficient machine learning capabilities able to determine and decode meaningful information from this data and that helps model future outcomes based on today’s information.

Going to the Cinema

Coded within the sounds made by the functioning heart is a wealth of diagnostic information. However, even to the best trained medical ear, these sounds are quiet and sometimes difficult or even impossible to perceive. When considering symptoms, one might think that the louder the sound the more significant the condition. This might be true with your failing car transmission or aging refrigerator but not always the case with your heart. Many critical sound symptoms are on the verge of perception and are easy to miss.

Clinical use of heart sounds has a very long history. Over time stethoscopes evolved to include the “bell” and “diaphragm” listening surfaces. Each aided differently in improving the audibility of difficult to perceive sounds. Modern digital stethoscopes essentially copy the sound filters of traditional stethoscopes.

One of the early things we did at Sparrow was to use spectral sound analysis to create a filter that greatly facilitates the perception of very quiet but important symptoms. In the process we removed the need for clinicians to have to switch between traditional filters to hunt for sounds. We call our filter a “Cinema filter” because it focuses attention on the most important things, making them clear and contrasted so you can pick out the nuances of the underlying story – kind of like going to a good movie.

Breath sounds

Bronchial breath sounds are loud, harsh breathing sounds with a midrange pitch (300 to 600hz). They are normal when occurring over the trachea during exhalation. These sounds, when emanating from another location, can be an indicator of a lung issue.  There are three types of abnormal bronchial breath sounds:

Tubular breath sounds are a high pitched  (600 to 1,200 Hz) bronchial breath sound. Some common conditions that produce these are:

  • Atelectasis: Partial or total collapse of a lung
  • Consolidation:  Air spaces within the lungs fill with liquid
  • Pleural effusion:  A buildup of fluid in the tissue  surrounding the lungs
  • Pulmonary fibrosis:  Damage and scarring of the lung tissue
  • Mediastinal tumor: A tumour in the area of the chest in between the lungs

Cavernous breath sounds are low pitched (100 to 300 Hz) bronchial breath sounds. Common conditions generating these are:

  • Lung damage from bronchiectasis
  • A lung abscess
  • Cancerous changes

Amphoric respiration is a type of abnormal bronchial breathing that creates a strong reverberating sound with high pitched overtones. it is an indication of a cavity, cyst, bleb, or other air-containing space in the lung communicating with the bronchial system

Listen: Rare musical diastolic murmur

A middle-aged man, prolapse of the right coronary aortic valve leaflet, severe aortic insufficiency. Rare musical diastolic murmur (1) and aortic ejection sound (2).