Such a device, Van Sickle thought, would give doctors data about when and where attacks occurred, helping them figure out possible environmental causes and allowing them to plan treatment accordingly.
In 2006, he began work on a prototype, an endeavor that turned out to be harder than he had imagined, chiefly because the sensor attachment had to be as durable as the inhalers themselves, which are often jostled around in pants pockets and handbags.
"The first prototypes were very ugly — like a coffee machine alongside of an inhaler," Van Sickle recalls. He says colleagues joked that just carrying one around might be stressful enough to induce an asthma attack.
Van Sickle and his team continued to fine-tune the technology, forming the start-up company Asthmapolis in 2008. The latest version of the inhalers is equipped with a smaller, Bluetooth-based device that sends usage information to a Web portal where maps show when and where patients have used their inhalers. Rajan K. Merchant, whose Woodland Clinic Medical Group outside Sacramento, Calif., began
The Asthmapolis inhaler is part of a burgeoning field called geomedicine, which uses geographic information system (GIS) technology to correlate environmental conditions with health risks. The hope is that this data, integrated into a patient's medical history, will help doctors and researchers fine-tune their diagnoses and treatments.
"Place should be a vital sign," says Ethan Berke, a spatial epidemiologist at Dartmouth Medical School in Hanover, N.H., and a family physician.
Doctors have long connected place and health, Berke says, pointing to John Snow, often called the father of modern epidemiology for his work linking London's 1854 cholera outbreak to drinking water contaminated by raw sewage. But today, technology has given them more precise and powerful ways to understand role of location in patients' health.
"I would love it if I could bring up [a] map and see the grocery stores, parks" that patients have recently visited "right there while you are checking their blood pressure," Berke says. Such information would allow him to better tailor his medical advice based on a patient's lifestyle."I can do that now, but I don't have many GIS tools in the exam room."
Since many medical conditions, including diabetes and heart disease, are linked to diet and lifestyle, doctors such as Berke who embrace geomedicine think more insight into their patients' lives will help them give advice that will be followed. If a heart attack patient, for instance, lives on the side of mountain on a narrow country lane with no sidewalks, it may be counterproductive to suggest taking daily walks around the block.
One of the chief instigators of this approach is Bill Davenhall, a manager at the GIS software company Esri. After he had a heart attack that he suspected was linked to environmental factors, Davenhall got Esri to build an app that integrates places a person has lived with a report of toxins found within three miles of those locations. Users can share that information with doctors.
Davenhall has been working with Loma Linda University Medical Center outside Los Angeles to integrate geography into patient treatment.
Dora Barilla, director of community health development at the medical center, says that it intends by early March to launch software interfaces that map the health status and local environments of more than a million of its patients.
The medical center plans to include on its public Web site information about disease hot spots and other data that until now has been stored in unwieldy databases. The site will also show maps of public resources such as grocery stores and parks.
These initiatives seek to understand how the place you live impacts the quality of your health, and then map out ways to address problems. For instance, soon Loma Linda doctors and case managers will be able pinpoint food pantries and soup kitchens in the medical center's service area, making it easier to suggest ones near the homes of low-income patients who need to improve their diet.
In Loma Linda, a password-protected system will allow caregivers to type in a patient's address and see neighborhood characteristics such as illness rates as well as resources for addressing them.
"It's mostly about connecting patients to resources and making sure unmet needs are getting met," says Barilla.
Other geomedicine technologies under development include Health Begins, a social networking platform that seeks to make clinicians more aware of socioeconomic factors that can affect health. The site, now in the testing phase, allows doctors, patients and family members to update entries, such as where to apply for affordable housing or how to contact a legal clinic for reporting unhealthy working conditions. The site also has a section that shows the latest research assessing links between social, economic and environmental factors and health.
Rishi Manchanda, the founder of Health Begins, says he became interested in geomedicine while working a primary-care physician in a poor section of Los Angeles, where he linked a patient's leaky, damp and moldy apartment to her allergy, sinus and migraine problems.
Rich Roth, vice president of strategic innovation at Dignity Health and others say they expect to eventually see "place" tools incorporated into electronic records to streamline use by doctors, nurses, social workers and others in the healthcare team.
"It wasn't until the role of the mobile phone became so permanent in our society that these sorts of geo-medicine apps became possible. You are not just talking about hypotheticals," says Roth, referring to the Asthmapolis trial. "We're using real data points in real time."
But such tools come with some potential downsides. Kate Black, an attorney focusing on health privacy at the Office of the National Coordinator of Health Information Technology, part of the U.S. Department of Health and Human Services, says, "Geomedicine is one of the great opportunities for technology in health care," but app developers ignore privacy concerns at their peril.
While patient information is filtered to remove names and other personal data, details can sometimes be traced back to the individual. "There's always a risk," Black says.
Apps that query information already in public view — such as the Google flu tracker — are less problematic than ones that ask users to input personal information, she says, because people may not understand that they are disclosing information that may later be sold to third parties without their knowledge or consent. This information could then be used to market to them products or services they don't want or used against them to determine such things as health-care coverage and premiums. And, she adds, people have reason to worry how such data can be used against them.
If companies can "learn that you've lived in these 14 neighborhoods, exposed to these 14 different risks, that might be the bases for denying you coverage," she notes.
"These apps need to be very clear about the data they use and whether they are disclosing it and how it will be used. Most of these apps don't do that," Black says.
Barilla, at the Loma Linda medical center, says privacy is such a big concern that administrators opted not to directly link patient medical records to the geographical tools. Instead, case managers will take the added step of plugging the patient's address into the publicly available databases on the medical center's Web site.
All it would take is one privacy-related controversy "to kill off this work," Barilla says. "So we are being cautious about privacy."
Van Sickle at Asthmapolis says his company has tackled privacy issues upfront.
"We give patients options to decide how much, if any, information they want to share. But we think there is lots to be gained by sharing," he says, adding that so far the company has found plenty of trial participants with "a willingness to give up a little bit of privacy as long as there are protections and trust and an agreement that [the information] will be used to help them and others with asthma."
Aggregate patient information is of interest to researchers such as Meredith A. Barrett, who works at the Center for Health and Community at the University of California at San Francisco.
"We'll be looking for hot spots in cities," she says, trying to figure out why people get asthma and what can trigger attacks. "And you could take climate-change information and use this type of geolocated data" to help predict outcomes, says Barrett, an ecologist who examines how environmental factors affect health.
In July, Van Sickle's GIS-enhanced inhaler received clearance as a medical device from the Food and Drug Administration. Asthmapolis has since since signed contracts to manage asthma patients for a Medicaid managed-care organization and a hospital. Van Sickle says the company is on track to distribute 25,000 to 30,000 units via similar contracts this year with hospitals, health insurers, pharmaceutical companies and other health-care providers.
And there have been surprises: The company's study in rural Wisconsin found people puffing on their inhalers more than urbanites, a finding that goes against what asthma researchers have long believed.
"It's these kinds of insights that we think will help us understand the origins of the disease," Van Sickle says.
For Tim Frank, a 44-year-old chef who lives in Woodland, Calif., the Asthmapolis inhaler has already yielded new insights about the asthma he's had since childhood. He says since he enrolled in the clinical trial last spring, he has noticed how often he needs his inhaler when driving past agricultural fields, where dust in the air apparently triggers his symptoms.
"It really helps, because I could avoid that area if I had to," he says. "I think that's the whole idea."