Digital and Mobile

Assoc Prof Robyn Whittaker, NIHI

Clinical Director of Innovation, Waitemata District Health Board

@rawegd

Wireless Households

- Living in poverty or near poverty

- Hispanic- Experienced

financial barriers to obtaining needed health care or have a usual place to go for medical care

• direct & personal

• frequent unsolicited reminders

• proactive

• in the moment

• personalised & tailored

• ask for help when you need it

• ongoing

• provides social support

Messaging supports behaviour change

Always on

Select quit

date (1-2

weeks out)

Countdown

1 SMS/day

Intensive

3 SMS/day

Maintenance

reduce in

frequency

~1 week 4 weeks ~20 weeks

6 months

mCessation: STOMP

Register mobile numberSchedules programme of messages according to rulesSends text messages at set

times/days

Who else are you giving up smoking for? Write down 4 people who will get a kick outa you kicking butt.

Hi Nick, how’s the cravings? They are worst after 2-3 days then they back off. Take it 1 day @ a time

Friends, whanau, hauora, mana, wairua all great reasons to me mutu (quit)

This is it! - QUIT DAY, throw away all your cigs. TODAY is the start of being QUIT forever, you can do it!

Cravings last less than 5 minutes on average. To help distract yourself, try sipping a drink slowly until the craving is over

Age

Gender

Ethnicity

Income

Region

Overall relative risk 2.8, 95% CI 2.1-3.5, p <0.0001

Rodgers et al 2005, Bramley et al 2005

− NZ national Implementation: same quit rate as phone counselling

− UK Text2stop (n=5800): doubled verified continuous abstinence at 6

months

− Cochrane Systematic Review Meta-analysis

− 12 RCTs 6 month cessation outcomes RR 1.67 (1.46-1.9)

− With verified abstinence RR 1.83 (1.54-2.19)

− Effective with & without first in-person visit

− Cost effectiveness

− Cost £278/quitter, future savings 0.5 QALY/quitter

− Promotion vitally important

− Ease of use, particularly

registration

− Add practical value

− Cheap or free

− Technology

National implementations

TextMATCH is a FREE text messaging

programme to support pregnant women

and their families with information

about eating well and being active.

Text Messaging for MATernal and Child Health

TextMATCH

TextMATCH

• Terms: Name, baby’s name and gender

• Timing: Estimated due date or birth date

• Relationship: Pregnant women or other family

• Culture: Ethnic group most identify with

• Language: Translated or English version

• Switch from pregnancy to baby messages initiated by user – Free text BABY

Kia ora [firstname]. Kua rēhita koe ki TextMATCH. Ka tuku i te 3 karere iti iho rānei ki a koe ia wiki mō te kai pai me te kori tinana i te wā e hapū ana

您的宝宝现在7周大，手臂和腿都正在生长。如果您想了解亚裔女士在妊娠期间可以得到的帮助，请致电华人社区服务中心 09 5701188

Iron is important to prevent you becoming too tired during pregnancy. Lean red meat, chicken, eggs, bajra flour, cowpea, masoor dal & moth beans contain iron

Give your baby the best start in life by not drinking alcohol or using drugs. Talk to your LMC or call the Alcohol & Drug helpline (0800 787797) for support

Talofa [firstname]. Keeping active towards the end of pregnancy can be tough but the health benefits make it worth it. Try swimming or a very gentle walk

Hi. Pelvic floor exercises are important and you can start these soon after you have had your baby. Discuss this with your midwife if you need more information

Development process

Direction (Roopu Kaitiaki)

Focus groupsDevelop Key

MessagesAdapt for SMS

Expert Review – TAG

Expert review – external

Cultural Adaptation

Cultural review

Translations Review Testing Roll out

Core messages adapted into four cultural versions

Words, tone, foods, activities, pregnancy practices

Reviewed to ensure cultural appropriateness and relevance

Maori, Pacific, Asian, South Asian

TranslationsChinese, Korean, Japanese, Te Reo Key words/terms in other languages

Dobson et al, 2017

Evaluation

− 1404 registrations in 18 months &

>98,000 messages sent

− 72% were mothers

− 19% actively discontinued

TextMATCH after an average duration

of 3.84 months

− 71% fully completed switch from

pregnancy to baby program phases

Version – Cultural group Language, relationship n Percentage

1 – Māori Te Reo, Mother 17 1.21%

2 – Māori Te Reo, Other 8 0.57%

3 – Māori English, Mother 173 12.32%

4 – Māori English, Other 55 3.92%

5 – Pacific English, Mother 244 17.38%

6 – Pacific English, Other 39 2.78%

7 – Asian Chinese, Mother 283 20.16%

8 – Asian Chinese, Other 67 4.77%

9 – Asian Korean, Mother 51 3.63%

10 – Asian Korean, Other 22 1.57%

11 – Asian Japanese, Mother 8 0.57%

12 – Asian Japanese, Other 0 0.00%

13 – Asian English, Mother 19 1.35%

14 – Asian English, Other 14 1.00%

15 - S. Asian English, Mother 222 15.81%

16 – S. Asian English, Other 182 12.96%

− All found messages relevant, culturally appropriate, and would recommend to others

− 93% said specific food practices & activities were appropriate

Interviews

Impact Number responded Response YES: n

(%)

Improvements to eating habits 29 18 (62%)

Improvements to family’s eating habits 29 16 (55%)

Positive changes to food shopping 29 19 (66%)

Positive impact on exercising 29 15 (52%)

Improvements to knowledge or understanding 29 21 (72%)

Feeling more supported 28 28 (100%)

“there’s a lot of time in isolation when it’s just you and bubba, it’s quite nice to receive that message”. [Māori, mother]

"[when it’s] a stressful time and then you get the message and realize you're not doing too bad" [Pacific, mother]

“it’s quite empowering actually just to get that little bit more information… you think you know everything after seven children so it’s actually quite cool”. [Māori, mother]

“Hi, your txts r really helpful. They give me helpful ideas for my son’s development. Thanks a lot”“Its great to listen from you the most useful tips…in fact it supports me n my kids in best way. I would say 100 out of 100 for you. Thanks for your support and care”

SMS4BG

• A theoretically based and individually tailored text message self-management support programme for adults with poorly controlled diabetes.

• Behaviour change• Motivational support• Diabetes education/

information

Goal settingSMS4BG: [hi] [firstname]. It’s a good idea to set an exercise goal to give you something to work towards, & then pick a reward for when you achieve it!

Problem solvingSMS4BG: Hi. Write down any obstacles or barriers to exercising (such as lack of time or bad weather), & then write down ways to overcome them

FeedbackSMS4BG: When you text us your blood glucose results we graph them. View your graph at www.diabetesstudy.co.nz. Username & password are your mobile number

Self-monitoring of behaviour

SMS4BG: [hi] [firstname]. Just a reminder it is time to check your blood glucose. Free reply text with the result

Social supportSMS4BG: Hi. Sometimes it can be tough trying to manage diabetes. Remember there are people here to support you, including [support1] & [support2]

Instruction on how to perform behaviour

SMS4BG: If you feel sweaty, dizzy, extremely hungry, confused or irritable you could be having a hypo. Test your blood glucose & quickly eat something sugary

Information consequencesSMS4BG: Good control of your blood glucose levels prevents long term damage to your body, & will help reduce many of the symptoms of diabetes

Prompts/cuesSMS4BG: [hi] [firstname]. If you forget to check your feet why not put a reminder in your phone or set an alarm to remind you

Behaviour substitutionSMS4BG: [hi] [firstname]. Changing habits is hard. Try swapping the time that you normally spend on something like watching TV with exercise

DistractionSMS4BG: [hi] [firstname]. Take a few minutes to focus on your breathing, saying to yourself CALM as you breathe in & RELAXED as you breathe out

Identification of self as role model

SMS4BG: Kia ora [firstname]. Taking a positive approach to living with diabetes will likely have a positive impact on the health & happiness of those around you

Framing/ reframingSMS4BG: If you get asked about diabetes at job interviews, mention the positive sides – managing diabetes takes discipline & maturity, which are great qualities

SMS4BG Structure

Core modules

Māori

Pacific

Non-Māori/ Non-Pacific

Insulin module

Young adult module

Smoking cessation module

Lifestyle behaviour modules

Exercise

Healthy eating

Stress and mood

Blood glucose monitoring

Foot care module

Cardiovascular check reminder

SMS4BG

− Tailoring variables:

− Choice of modules

− Length of programme (3 – 9 months)

− Timing of messages

− Personalisation variables:

− Name

− Cultural version

− Names of 2x support people

− Motivations for good diabetes control i.e. grandchildren,

career

− “I thought they were really good and really helpful, because it’s like having your

health professional there in your ear just reminding you, but you didn't have to ring

them or see them, they were good and kept you focussed”

− “Messages kept me thinking/remembering about diabetes so that even when a

message came that wasn't a reminder message it still made me think about when I’d

last tested, if I needed to take any insulin, just kept diabetes in the forefront of my

mind.”

− “They were really really good. Some of them I knew I had been told by my doctor

but when you're in with them you know it and when you come out it's hard to

remember so it was really good to get the reminder of things that I’d forgotten. Prior

to the program I was testing sporadically, throughout the program just became more

of a habit to always test”

Reminders

− “The motivational messages, I found them more helpful particularly when they were

telling me to do things for my family, that’s the lever for me”

− “Empowerment I have felt by the constant text messages. They felt cumbersome and

overwhelming at times but to have come out the other end and see the results is

fantastic - my HbA1c is the lowest it's been in 12 years, I'm more active, can spend

more time with my kids, and I will live a longer life because of it”

− “Sometimes I don't have a lot of motivation - receiving the messages gave me a

boost and made me feel more confident, like someone else understood.”

Motivation

− “Made you realise that there was someone out there. It reduced feelings of isolation,

and made you realise you weren't alone.”

− “My family has been going through a tough time and the support was great.

Messages helped me keep my diabetes under control, reminded me of why I should

keep trying. The messages supported me when my family wasn't able to.”

− “Nice to know that someone is there to care for you, like an angel of hope. Reminder

all the time, always there.”

Social Support

− “I felt more in control of my diabetes and that flowed into other areas of my

life where I felt more confident. It kept it at the forefront of my mind so it

impacted everything. I didn’t learn anything new, for me it was about

behaviour modification and it worked. I would love it to continue.”

PROVISIONAL Results

− Significant decrease in HbA1c at 9 months HbA1c in the

intervention group compared with the control group

− Significant differences between groups at 9 months for:

− Foot care behaviour

− Overall diabetes support

− Quality of life health status

CoDesign of Personalised Healthy Lifestyle Support for Maori and

Pasifika (WellText)

Work with users to establish

goals

Learn about users’ needs

and experiences

Turn ideas into possible

interventions

Partnerships

• Co-Investigators multiorganisational representing Maori, Pacific, behaviour change, wellness, nutrition, mHealth, technology development

• Partnered with 2 Maori communities and 2 Pacific communities via community organisations & representatives

• Multiple hui, workshops, focus groups

Models

Co-design

1. Opportunity Identification

2. Generation of explicit and

implicit knowledge

3. Identification of needs and

desires

4. Description of mHeallth

requirements

5. Envisioning the mHealth

tool

6. Prototype development,

testing & evaluation

Te Whare Tapa Whā model (Durie, 1994)

Fonofale model (Pulotu-Endemann, 2001 )Participatory co-design cycle adapted from Bratteteig (2003)

OL@-OR@ App

Cardiac patients

Text Message and Internet Support for

Coronary Heart Disease Self-

Management: Results From the

Text4Heart Randomized Controlled

Trial

J Med Internet Res. 2015 Oct; 17(10): e237.

Published online 2015 Oct 21. doi: 10.2196/jmir.4944

Conclusions

A mHealth CR intervention plus usual care showed a positive

effect on adherence to multiple lifestyle behavior changes at 3

months in New Zealand adults with CHD compared to usual

care alone. The effect was not sustained to the end of the 6-

month intervention. A larger study is needed to determine the

size of the effect in the longer term and whether the change in

behavior reduces adverse cardiovascular events.

Date of download: 10/5/2017Copyright © 2015 American Medical

Association. All rights reserved.

From: Effect of Lifestyle-Focused Text Messaging on Risk Factor Modification in Patients With Coronary Heart

DiseaseA Randomized Clinical Trial

JAMA. 2015;314(12):1255-1263. doi:10.1001/jama.2015.10945

Primary and Secondary End Point Analyses at 6 Months Follow-upa

REMOTE-CR System

Exercise PhysiologistsPatients

The Cloud(web servers)

Sensors Mobile app Web app

Problem Gambling

− Has the best reach into all populations

− Is effective in supporting healthy behaviour change and self-

management of long term conditions

− Can be delivered in a variety of ways/modalities

− Can be enhanced with incoming individual data from

wearables, sensors, health information systems to further

personalise and engage participants

− Can be linked with other services (your clinician, in-person

support, group sessions, post-hospitalisation)

− Is part of providing ‘anytime anywhere care’

Messaging

Robyn, step

away from

that cake.

Mobility in the DHB

Laying the foundation for mobility

Policy, governance

Infrastructure

Authentication

Security

WiFi everywhere

Mobile Device Management

Service

Mobile Enterprise Application

Platform

App approval &

development

In hospitalimproving mobility for clinicians

• voice-to-text dictationreducing transcription time & getting docs out quicker

• MyPatientList

A new way of working on our wards

• e-vital signs system

• ePrescribing & administration

• eOrders

• >2500 users, 30 iPads, 450 iPad minis, 150 CoWs

• Saving each RN & HO ~20mins/shift

• Saving >100kg paper/week

Outside the hospitalimproving mobility for clinicians

• community mobilitymobile devices enabled for clinicians supporting patients in the community to capture patient notes and as a therapeutic device

Outside the hospitalimproving mobility for clinicians

Did the pictures/information/resources on the iPad help you understand your health?

2316

Older adults & home health

Child, Women & Family

n = 304

EBP upper extremity stroke rehabilitation

• “having this technology is vital – it enhances the service we provide” (AH leader)

• “I have enjoyed seeing patient’s understanding improve with easier access to education through the iPad” (therapist)

• “I feel I am providing a better service as a health professional”(therapist)

Outside the hospitalimproving mobility for clinicians

“I could see the volume …using the decibel/sound level meter app made it easier to understand the purpose of the speech therapy

activities” (patient)

“I find videos and pictures very helpful to learn…really helpful to see what happens

when Nick swallows” (patient’s wife)

Parkinson Disease & Vocal therapy Dysphagia education

Process

http://staffnet/wdhbmobileapprequest

Apps

patient engagementimproving patient experience

• free Wi-Fi for patients and visitors

• patient engagement systemipads at the patient bedside forentertainment, connection and information

Kiosks/Outpatient Journey

VR

a new way of working

• Anywhere, any time

• Mobile first

• Ease of use

• Data driven + value add

• Supporting/enabling patients

• If we don’t do it…

Moving from a location & provider

centric system to anytime anywhere

care

− Improving access to health information,

support & services when and where

needed

− Empowering communities to be healthy

− Motivating and supporting

individuals/families to manage their

health

Where is this heading?

Wearables

"Wearable will go from looking at what happened to doing dynamic predictions and preventions – for example, predicting heart failure or seizures on a personal level, or predicting epidemics on a population level."

Ingestibles

Passive

Virtual/Remote

Avatars

AI

Next IT’s sophisticated artificial intelligence technology builds a relationship with your patient through concierge-like service that continuously engages and motivates on a personal level. Alme Health Coach can be configured for specific diseases, medications and treatments, providing patients, doctors and caregivers with trusted information and an effortless experienceDrive adherence“One of the leading issues in healthcare is non-adherence to treatment plans and prescription drug regimens. Alme Health Coach goes beyond the simple pill reminder to ensure that adherence is achieved. The virtual health assistant, or VHA, alerts patients to take their medications, addresses any questions or concerns, notifies care teams when non-adherence arises and congratulates your patient when treatment plans are followed as prescribedIntegrate Alme Health Coach not only integrates seamlessly into a patient’s life, but also with the systems around them. APIs within Alme Health Coach enable third-party integration with wearables, devices, native phone functions, enterprise systems, EHRs and more.”

“based on all of your health information, and data from 000,000’s of other patients who had similar characteristics/results at some point, the best next treatment for you is…”

Clinical tools

oDocs Slit Lamp Adapter

An affordable and universal slit lamp microscope adapter for smartphones. It comes with its own

eye piece with superior optics. Anterior segment clinical photo-documentation is now made easy

with oDocs Slit Lamp Adapter. 3D printable STL files are also available.

The OphthalmicDocs Fundus is a 3D printed universal

smartphone retinal imaging adapter. It is capable of

taking high quality retinal images with up to 40 degree

field of view. This is the world's first open source

smartphone retinal camera project. The files are freely

available online. Please download them and contribute.

Lab in every bathroom

Tricorder

IoT/Smart homes

Amazon EchoEcho, always listening via Amazon’s Alexa voice service, lets you play music, order pizza, and get questions answered, and can control popular smart-home devices and 1,000-plus other things.$180 from Amazon$100 from Target

DIY

@rawegd

http://i3.waitematadhb.govt.nz

www.nihi.auckland.ac.nz

r.whittaker@auckland.ac.nz