App with a Heart

The day of discharge from the hospital – any hospital — is like being at a bad party or uncomfortable family reunion.  It’s interminable.  Everybody’s ready for it to be over, including you; you just want to go home.

 Shortly before it’s time to go, a nurse goes over your discharge instructions.  Maybe you nod a lot – but maybe you also glaze over, feeling too worn out or overwhelmed to think about the big list of medications and follow-up appointments.

If this haziness about what you’re supposed to do when you leave the hospital sounds familiar, that’s because you’re not alone.  It happens to a lot of us, and this is not good; that discharge information is crucial.  More than 39 million hospital discharges happen every year in the U.S., and nearly 20 percent of those people wind up back in the hospital within a month.   

Francoise Marvel

Courtesy of FSU College of Medicine

These are dismal statistics.  Francoise Marvel, M.D., a second-year resident in internal medicine at Johns Hopkins Bayview Medical Center, wants to change them – starting with helping heart attack patients who are at highest risk of being readmitted within that critical first 30 days.  I recently interviewed Marvel for Breakthrough, the magazine for the Johns Hopkins Center for Innovative Medicine.

Her key to helping these people recover: their cell phones. 

Studies show that about 80 to 90 percent of Americans own a cell phone capable of receiving medical information.  Rich or poor, young or old, tech-savvy or not; doesn’t matter.  Cell phones transcend demographics.

“Unfortunately,” says Marvel, who plans to specialize in preventive cardiology, “hospital discharge is a process that is fraught with patient safety issues.”  The discharge instructions are often written by an intern or medical student, and frankly, the quality varies.  That information is then handed off to a nurse, who conveys it to the patient.

Also, the timing is bad.  Patients may get the go-ahead to leave in the morning, but the actual discharge usually doesn’t happen until late afternoon.  The day drags on, and the last thing those people may feel like doing is sitting through a mini-seminar on medications, lifestyle and dietary changes.     

And yet – especially for those who have stents put in to help a clogged artery stay open – understanding and following this information truly is a matter of life and death.  Another problem, says Marvel, is that the proverbial wheel is being reinvented with every patient.  If you have been a heart patient yourself or been in the hospital room with a relative who has, you know the drill:  Go to cardiac rehab, avoid salt, measure your pulse and blood pressure, avoid alcohol and stop smoking.  Etc. 

But if you have a newly placed stent, what you hear in those discharge instructions is extra important: You must take aspirin and Plavix, two essential blood-thinning medications – these allow your blood vessel to knit a blanket of cells to cover the stent.  That stent is very sticky. Until the cells grow around it, without those blood thinners it’s almost certain that a clot will form. 

That message doesn’t always come through loud and clear, and some patients don’t understand the urgent need to take these pills every single day and not stop for any reason, and that “if they don’t do this, they will have a massive heart attack.”

This is far too important to tell people “right before they get in a wheelchair and get picked up by a family member,” says Marvel.  She cites a 2013 study published in the Journal of the American Medical Association, showing that 40 percent of patients over 65 “who felt that they had a good understanding of their discharge instructions” could not accurately describe the reason for their hospitalization, and 54 percent “did not accurately recall instructions about their follow-up appointment.”

hospital doorAnother study of recently discharged patients aged 64 and older found that “the majority did not understand the new dosing of medications they were taking” or the reasons for medication changes.  “What we know from the research,” Marvel says, “is that many patients are likely to come back to the hospital for avoidable reasons,” and the discharge process is largely to blame.

She is designing the Health-e App for smartphones.  It will serve as a “discharge navigator,” helping patients transition from the hospital to the home after a heart attack.  Designed for people who, like most of us, “don’t know the first thing about cardiac rehab,” the app will help patients follow up with the heart doctor and connect with a pharmacy.  It will walk them through changing their diet and also will connect patients with social services and help them apply for insurance if they don’t already have it.

  After a heart attack, most patients stay four days.  Marvel plans to give the app on Day 2, to “so they feel comfortable with it and have a chance to preview the app so they’ll know why and how they need to take care of themselves when they get home.”  This user-friendly, guided, evidence-based approach, she envisions, will be much better than “the four to five pages of relatively unhelpful, EMR (electronic medical record)-automated, inconsistent instructions.” 

The American Heart Association estimates that one in five men, and one in four women, die within a year after having a heart attack.  “Looking at the risk factors for why you would die within that window, medication and therapeutic adherence – knowing what you need to do and take, and being consistent – is the number one reason,” Marvel says.  “It keeps you up at night when you realize we keep giving the same basic instructions that were typed out 50 years ago. We’re doing a huge disservice to our patients.”

Smart phones, Marvel says, can become a tool for “wraparound care.”  But right now, hospitals are not routinely using them as such.  “If I ask you, where are your car keys, you might have to think about it.  But if I ask, where’s your phone, you know where it is.  You’re wearing it, or it’s right beside you.”  She believes that using the cell phone “is going to bring us closer to our patients.  In the hospital, they see us for 15 minutes, maximum, when we’re on rounds; in fact, that’s a long encounter.  It could be as little as four or five minutes.”

Marvel is developing a prototype with the help of student volunteers from the Johns Hopkins Whiting School of Engineering.  She estimates that the total cost will be $150,000. 

©Janet Farrar Worthington

Regular disclaimer: This is a blog. It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional.

Coming Soon: A “Smart Watch” for Acupuncture

Medicine wears off.  If you take a pill, its benefit might last for 12 or even 24 hours, and then you have to take another one.  The same holds true for acupuncture.   Although administered differently – inserting very thin needles through your skin at strategic points – its effects tend to fade just as quickly. 

There’s one big difference:  Most people who get acupuncture only have it once or twice a week, at most. Imagine if you had an antibiotic that worked, and you only took it once a week. 

Jiande Chen, PhD.

Courtesy of Johns Hopkins Medicine

Jiande Chen, Ph.D., a Johns Hopkins biomedical engineer working with the Amos Food, Body, and Mind Center, is about to change this.  I interviewed him recently for Breakthrough, a magazine for the Johns Hopkins Center for Innovative Medicine.

Chen specializes in the pathophysiology of gastrointestinal motility – how food moves through your body — as well as diabetes and obesity.  He is particularly interested in electrical therapies that stimulate the nerves involved in gut function, and now he has developed a novel device for patients to use at home that provides “transcutaneous electrical stimulation” similar to the effect of acupuncture.

In other words, he’s developed a smart watch for acupuncture. 

Requiring only a watch battery, it delivers a painless, noninvasive dose of electric current that penetrates as deeply and precisely as one of those long, thin needles.  But patients can administer it themselves, at home, after every meal. 

It’s safe, DIY home acupuncture, and it might significantly change the way people with certain conditions, starting with gastroparesis, find relief.

In gastroparesis, the stomach is slow to empty.  Food lingers because the muscles that should move it along to the gut – squeezing it like toothpaste through a tube – are either damaged or weak.  One big cause is diabetes.  The condition can be miserable and can include decreased appetite, heartburn, nausea, vomiting, bloating, anxiety, and discomfort.  Symptoms are usually treated with medicine and dietary changes, but in a recent study, Hopkins scientists showed that acupuncture can also help relieve symptoms. 

 Now, let’s switch for a moment and look at gastroparesis as an acupuncturist would. In traditional Chinese medicine, a complex system of healing more than 5,000 years old, practitioners believe our vital energy, called “qi” (pronounced “chee”), flows through the body along 12 pathways, called meridians.  Each meridian involves a different organ system. 

When all is well, the qi flows smoothly; but when there is an imbalance somewhere, the flow is blocked or hindered, and that’s how disease can begin.  The needles inserted during acupuncture are designed to restore this balance.  Gastroparesis might be called “food stagnation,” or “liver and spleen disharmony” in Chinese medicine, but the basic problem would be the same: food not moving through the digestive tract.  The liver is supposed to ensure that everything – digestion as well as emotions – flows smoothly.  When this flow is blocked, it weakens the spleen, which is in charge of digestion.

Acupuncture stimulates nerves – in this case, the vagus nerve, which reaches all the way from the brain down through the esophagus, heart, and lungs, down to the abdomen, and controls many things, including digestion.  It also stimulates blood flow by dilating blood vessels and causes the body to release endorphins, natural painkillers.

In someone with gastroparesis, acupuncture sends a signal to the brain via the vagus nerve, telling the stomach to work better.

Chen’s device works by neuromodulation, using electrical stimulation to change how nerve cells interact. In painstaking research, he has determined the precise levels needed to produce a beneficial change in the function of the nerves – how much energy to release, the speed of the electrical signal, the width of the pulse. 

That precision “is one difference between our method and traditional Chinese medicine.”  Another is frequency:  “It would be very expensive to do traditional acupuncture two or three times a day, but with this device, you are just putting an electrode at the acupuncture points.  You could do it after every meal.”

There are two key placement points:  One is the wrist, “which is very good for treating symptoms like nausea, vomiting, and motion sickness.  That wrist acupuncture point is very close to the medial nerve.” The other is about 5 centimeters below the knee, a place called “stomach point number 36” in acupuncture.  “This is very close to the perineal nerve,” and stimulation here “is known to enhance the autonomic nerve function, which helps empty the stomach and improves the digestive process.”

Basically, Chen explains, “We combined modern neuromodulation theory with traditional Chinese acupuncture.”  This is just the kind of project its leaders envisioned when the Amos Food, Body, and Mind center began a year ago: blending Eastern medicine with state-of-the-art technology in a holistic, whole-body approach to improving health. 

The device has not yet received FDA approval and it doesn’t work for everyone, Chen notes, “but our results of early studies are very exciting.”  In related work, Chen plans to see whether the device can help improve symptoms in patients with scleroderma and whether it can help reduce the appetite in people with obesity.

©Janet Farrar Worthington

Regular disclaimer: This is a blog. It is not an encyclopedia article or a research paper published in a peer-reviewed journal. If a relevant publication is involved in the story, I mention it. Otherwise, don’t look for a lot of citations, especially if I’m quoting from a medical professional.