Clinical Associate Professor, Medicine
Rationale and design of a large-scale, app-based study to identify cardiac arrhythmias using a smartwatch: The Apple Heart Study.
American heart journal
BACKGROUND: Smartwatch and fitness band wearable consumer electronics can passively measure pulse rate from the wrist using photoplethysmography (PPG). Identification of pulse irregularity or variability from these data has the potential to identify atrial fibrillation or atrial flutter (AF, collectively). The rapidly expanding consumer base of these devices allows for detection of undiagnosed AF at scale.METHODS: The Apple Heart Study is a prospective, single arm pragmatic study that has enrolled 419,093 participants (NCT03335800). The primary objective is to measure the proportion of participants with an irregular pulse detected by the Apple Watch (Apple Inc, Cupertino, CA) with AF on subsequent ambulatory ECG patch monitoring. The secondary objectives are to: 1) characterize the concordance of pulse irregularity notification episodes from the Apple Watch with simultaneously recorded ambulatory ECGs; 2) estimate the rate of initial contact with a health care provider within 3 months after notification of pulse irregularity. The study is conducted virtually, with screening, consent and data collection performed electronically from within an accompanying smartphone app. Study visits are performed by telehealth study physicians via video chat through the app, and ambulatory ECG patches are mailed to the participants.CONCLUSIONS: The results of this trial will provide initial evidence for the ability of a smartwatch algorithm to identify pulse irregularity and variability which may reflect previously unknown AF. The Apple Heart Study will help provide a foundation for how wearable technology can inform the clinical approach to AF identification and screening.
View details for PubMedID 30392584
Healthcare Service Utilization under a New Virtual Primary Care Delivery Model.
Telemedicine journal and e-health : the official journal of the American Telemedicine Association
BACKGROUND: Telemedicine holds great promise for changing healthcare delivery. While telemedicine has been used significantly in the direct-to-consumer setting, the use of telemedicine in a preventive primary care setting is not well studied.INTRODUCTION: ClickWell Care (CWC) is the first known implementation of a technology-enabled primary care model. We wanted to quantify healthcare utilization of primary care by patient characteristics and modality of care delivery.MATERIALS AND METHODS: Our study population included those who completed a visit to a CWC clinic between January 1, 2015 and September 30, 2015. We compared patients based on utilization of CWCs in-person and virtual visits across the following domains: patient demographics, distance from clinic, responses to a Health Risk Assessment, and top 10 conditions treated.RESULTS: Thousand two hundred seven patients completed a visit with a CWC physician in 2015. Nearly three-quarters of our patients were ≤40 years and sex was significantly different (p=0.015) between visit cohorts. The greatest representation of men (47%) was seen in the virtual-only cohort. Patients' proximity to the clinic was also significantly different across visit cohorts (p=0.018) with 44% of in-person-only and 34% of virtual-only patients living within 5 miles of Stanford Hospital.DISCUSSION: We found men were more likely to engage in virtual-only care. Young patients are willing to accept virtual care although many prefer to complete an in-person visit first.CONCLUSIONS: Our findings suggest that a "bricks-and-clicks" care model where telemedicine is supported by a brick-and-mortar location may be an effective way to leverage telemedicine to deliver primary care.
View details for PubMedID 30192211
New Delivery Model for Rising-Risk Patients: The Forgotten Lot?
Telemedicine journal and e-health
Shared-risk models encourage providers to engage young patients early. Telemedicine may be well suited for younger, healthier patients although it is unclear how best to incorporate telemedicine into routine clinical care.We test the assumptions surrounding the use of telemedicine, younger and rising-risk patients, and primary care in ClickWell Care (CWC), a care model developed at our institution for our own accountable care organization.CWC's team of physicians and wellness coaches work together to provide comprehensive primary care through in-person, phone, and video visits. This study examines usage of the clinic over its initial year in operation.1,464 unique patients conducted a total of 3,907 visits. 2,294 (58.7%) visits were completed virtually (1,382 [35.4%] by phone and 912 [23.3%] by video). Patients were more inclined to see the physician in-person for a new visit (1,065 visits [70.5%] vs. 362 [24%] phone and 83 [6%] video) and more likely to see the physician virtually for a return visit (606 [43.2%] phone and 249 [17.7%] video vs. 548 [39.1%] in-person), a statistically significant difference (X(2) = 306.7, p < 0.00001).This new care model successfully engaged a younger population of patients. However, our data suggest young patients may not be inclined to establish care with a primary care physician virtually and, in fact, choose an initial in-person touch point, although many are willing to conduct return visits virtually. This new model of care could have a large impact on how care is delivered to low- and rising-risk patients.
View details for DOI 10.1089/tmj.2016.0181
View details for PubMedID 28375821
A 15-year review of the Stanford Internal Medicine Residency Program: predictors of resident satisfaction and dissatisfaction
ADVANCES IN MEDICAL EDUCATION AND PRACTICE
2017; 8: 559–66
Satisfaction with training and with educational experiences represents important internal medicine (IM) programmatic goals. Graduates from IM residency programs are uniquely poised to provide insights into their educational and training experiences and to assess whether these experiences were satisfactory and relevant to their current employment.We surveyed former IM residents from the training program held during the years 2000-2015 at the Department of Medicine, Stanford University. The first part of the survey reviewed the IM residency program and the second part sought identifying data regarding gender, race, ethnicity, work, relationships, and financial matters. The primary outcome was satisfaction with the residency experience.Of the 405 individuals who completed the Stanford IM residency program in the study period, we identified 384 (95%) former residents with a known email address. Two hundred and one (52%) former residents responded to the first part and 185 (48%) answered both the parts of the survey. The mean age of the respondents was 36.9 years; 44% were female and the mean time from IM residency was 6.1 (±4.3) years. Fifty-eight percent reported extreme satisfaction with their IM residency experience. Predictors associated with being less than extremely satisfied included insufficient outpatient experience, insufficient international experience, insufficient clinical research experience, and insufficient time spent with family and peers.The residents expressed an overall high satisfaction rate with their IM training. The survey results provided insights for improving satisfaction with IM residency training that includes diversifying and broadening IM training experiences.
View details for PubMedID 28814910
- The Outlook of Digital Health for Cardiovascular Medicine: Challenges but Also Extraordinary Opportunities. JAMA cardiology 2016; 1 (7): 743-744
- 27580275 The Outlook of Digital Health for Cardiovascular Medicine: Challenges but Also Extraordinary Opportunities. 2016