Emerging Technologies for Patient Engagement and Mobile Health
DoD & VA EHR Symposium
Kenyon Crowley MBA MS CPHIMS
October 1, 2013
Agenda Briefly who CHIDS is
Patient engagement and activation
Tools and technologies being deployed in pursuit of activating patients
Importance of design
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Strategy
Technology Policy
About CHIDS Center for Health Information & Decision Systems
Mission
Research, analyze, and recommend solutions to challenges surrounding the introduction and integration of information and decision technologies into the health care system
Improve the practice and delivery of health care by offering researched solutions that impact safety, quality, access, efficiency, and ROI
Partner Ecosystem
Federal and state agencies (HHS, NSF, ONC, FDA
DOD, State of MD)
Private corporations (Children’s National, J&J, CareFirst BlueCross BlueShield, Cisco, Small and Mid-Size firms)
Not-for-profits (CDT, eHealth Initiative)
Resources
Renowned scholars from multiple disciplines
Research fellows, students, partners
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Research Focus Areas
Impact and Comparative
Effectiveness of Health Information
Systems
New Models of Care (ACO, HIE,
PCMH, Care Transitions)
Healthcare Analytics (Data-
driven Health Services Insights,
Modeling, Operations)
Consumers, Quality &
Transparency, and Social Media
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Terminology “Patient activation” refers to a patient’s
knowledge, skills, ability, and willingness to manage his or her own health and care.
“Patient engagement” is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly.
“Mobile health” is the application of wireless and mobile technologies designed to improve health research, health care services and health outcomes. (Not just apps and phones)
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Potential impacts
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Source: Veroff D. et al. (2013) Health Affairs
Barriers to patient engagement Patients
Lack of health literacy
Only 12% of patients can fully understand the information given to them to make proper health decisions
Diversity of patients
Cognitive differences among patients
Extreme sensitivity to costs
Poor usability of systems
Laziness – may offend patient advocates but true in many cases – also known as the “why diet when there’s a pill for that syndrome”
Providers
Overworked physicians indicate cannot do more
Pushback from healthcare providers when they are held accountable for their patient’s actions
Insufficient provider training
Inadequate clinical information systems
70% of physicians believe health IT tools will cost more than the benefits received
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Effective Patient Engagement Strategy Shared decision-making among patients and clinicians
Provide patients with information they are able to understand
Teach patients and families how to manage their conditions
Use easy-access + easy-to-use technology for patients to engage
Have a comprehensive and historical patient record, and effective patient identity management method
Track and share the impact of activities on patient health
Get feedback from patients (surveys, focus groups, complaints)
Get patients involved in an advisory capacity
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A framework for patient engagement
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Source: Carmen K. et al. (2013) Health Affairs
Patient engagement tool: Mobile Health 85% US adults own mobile phone; 53% own
smartphone.
19% of smartphone owners have at least one health app on their phone. Exercise, diet, and weight apps are the most popular types.
One in three cell phone owners (31%) have used their phone to look for health information. (17% one year ago).
According to a March 2013 study, the market for mHealth services has now entered the commercialization phase and will reach $26 billion globally by 2017.
Market forecasted to grow at a CAGR (compound annual growth rate) of 40.4 % through 2015.
According to research by HIMSS Analytics, about half of all doctors use mobile health apps, and a quarter of consumers do.
Sources: Pew Mobile Health Survey 2012,
Mercom Report 2013, Image – Rock
Health
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Continuum of mHealth Tools
Source: Nilsen W (2012) NIH 12 10/01/2013
BioZen developed by DoD Portable, low-cost way for
patients and physicians to receive biofeedback in and out of clinic
Show real-time data from multiple body sensors
Create notes for recording session
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PE (Prolonged Exposure) Coach by DoD and VA
Support the tasks associated with prolonged exposure treatment of PTSD
Aid patients and therapists during clinical care
Streamline the professionally-guided treatment of PTSD
Interactive respiration retraining
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Life Armor for military community Browse information on 17 topics,
including sleep, depression, and post-traumatic stress
Measure and track symptoms by self-assessment
Watch videos relevant to each topic from veterans, military family members and other service members
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PTSD Coach used in VA & DoD Self-Assessment
Manage Symptoms
Find Support
Learn about PTSD
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Big issues Limited number of mobile health apps are
constructed on design principles that are theoretically derived, and little is known about their effectiveness.
How to sustain use?
Military context – Numerous device security issues
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Patient engagement tool: Secure Messaging Secure messaging offers patients, their caregivers, and/or advocates the
ability to communicate securely and electronically with health care providers.
The secure messaging framework is built around existing communication tools such as the patient portal, secure email, and the PHR.
The correspondence can be initiated by either the patient, caregiver or the provider.
Messaging may contain structured, unstructured or mixed format content.
PHRs often have a secure messaging system with security greater than standard emails.
10/01/2013 18 Source: HRSA
Air Force PHR / SM Study Air Force Medical Service implementation of a PHR with
secure messaging (SM) in Dec 2010 at Joint Base Richardson-Elmendorf in Alaska
Part I Objective: Determine factors that influence patients’ intentions to use PHR
System capabilities and benefits used: Request your next appointment Request medication renewals Receive your test and lab results Maintain a Personal Health Record (PHR) to manage your health Communicate online with your healthcare team about non-urgent symptoms Avoid unnecessary office visits and telephone calls Request a copy of your immunization record Access a large library of patient education materials Additional features have come online since 2010
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Patient Enrollment Process & System Interaction
Elmendorf
MTF Registration Desk
INTERNET
MiCare Portal
(PHR/SM)
Visit MTF to
register (show
military ID)
Updates to PHR,
messages to/from
providers
Patient registration
information Patient’s medical
information
Messages to/from
patients
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Summary of Early Findings
Positive “expectations” among patients, less so for providers
Adoption is trending up but still low
Key is personal promotion and recommendation to patients by providers
Usage is low Provider-initiated secure messaging
Identification and designation of super users
Compelling “use” stories
Overcoming provider resistance Realistic messaging and expectation management
Sufficient training of providers/staff
Workflow and business rules
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Air Force PHR / SM Study Part II Objective: Assess impact of PHR/SM on health
services utilization
Primary Care Appointments
Telephone Consults
Emergency Room Visits
Inpatient Stays
Clinical outcomes
Comparing portal users to similar non-users
Analysis in progress
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More tools: Era of the Quantified Self and Trackers
7 in 10 US adults keep track of a health indicator
60% of US adults say they track weight, diet, or exercise routine
New ways for easing burden data entry resulting in increased monitoring and support services
Popular in employer wellness initiatives
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Source: Tracking for Health (2013) Pew Internet
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Games for Health
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Definition: application of game psychology to health tasks
Why Games? Structure information such that a complex topic is
more accessible
Decades of research has provided insights about how people learn and change their health behaviors --- We can integrate this understanding into the design of highly engaging health games
Game play can influence risk perceptions, knowledge, skills, and self-confidence
Foster peer influence
Done well can be fun
Military environment – already sense of teams, competition to leverage
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Health gaming @ CHIDS w/ VA Mobile Social Engagement For Older Adults
Management of Diabetes Type II Design elements that facilitate older adults’ adoption and use of new
technology, particularly for health-related purposes
Examine the stages of behavior change from the initiation of the intervention to behavior maintenance, including the examination of intervening variables
Social and behavioral aspects of disease management
Combing provider influence with peer influence
Use of health coaches
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Social engagement research Impact of different types of rewards and
incentives
Personalization of health message content and frequency
Optimizing team structures
What educational materials improve health literacy
Personality-driven interactions
Data capture ease of input
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VA Mobile Health Family Caregiver Pilot
May 2013, Caregivers began receiving VA-loaned iPads loaded with a Suite of Apps to test over a 12-month period
Care4Caregiver
Health Advocate
Health Assessment
Journal
Notifications and Reminders
Pain Coach
PTSD Coach
RxRefill
Summary of Care
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2 graphs
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Segmenting market players
Zombies, Run! Top paid health and fitness apps #4
Key = Fun
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Mango app Health education and adherence with rewards including social
conscience type rewards
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mHealth Products versus Platforms
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Aetna CarePass API’s (subset)
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Blue Button+ API
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“All patients whose providers use Meaningful Use Stage 2 certified
technology have the ability to view, download, and securely
transmit their clinical data from their provider’s Electronic Health
Record into another product or holding place of their choice”
ONC Blue Button Co-Design Challenge
Implementation guide at http://bluebuttonplus.org/index.html
Open mHealth
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PTSD management
Type II diabetes
Health 2.0
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Data Source
Rare disease community Amyotrophic Lateral
Sclerosis (ALS)
Data collected using web crawler Patient profiles Threads and replies in
forum (reflects participation)
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Threads vs Replies
Thread
Reply
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PLM online community ALS
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Methods and Main Findings
• Exponential random graph models
• Track direction, content and reaction to information shared
in social networks
• Net inflow from urban to rural patients participating in an online
health community
• Disease prognosis, treatment experiences, emotional
Role of Design in Patient Engagement
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“Long dominant in online search,
advertising, and maps, Google has shifted
gears from utility to beauty” Fast Co. 2013
Consumer‐friendly design can make the difference between
incomprehensible and meaningful, between information overload
and health data that’s personal, relevant, and actionable. Thomas
Goetz TEDMED 2013
“A smart product is built with the human
form in mind: Rather than us having to
integrate it into our lives, the product
instinctively conforms to us.” Margaret
Rhodes
Many promising inventions flop, not because they aren't
useful, but because they aren't appealing. Kenyon
9/30/13: Apple surpasses Coke
as most valuable brand
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Designing consumer HIT applications Use methods that include high levels of user involvement and
iteration. Iterate and involve users early and often.
Use prototypes and consumer feedback based on their use of the prototype.
Most products use one or more of the following design methods: prototyping; agile development; heuristic evaluation; top-down design; lean product development; and Goals, Operations, Methods, and Selection Rules (GOMS).
Ensure the design team has medium breadth in regard to team size and the skill-sets represented.
Engage human factors experts in the design team.
“Keep it simple” - Choose a parsimonious set of features to include in the application.
Pay careful attention to user characteristics and context of use
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It takes an ecosystem…
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Innovation and Value
Customers
Employees
Scientific Community
Partners
Other Stakeholders
Thank You! Kenyon Crowley
@healthIT
Website: http://ter.ps/chids
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“if you want to understand a sales person’s behavior, study
their commission plan. If you want to understand a doctor’s
behavior, understand their reimbursement model.”
- Leonard Kish