Mobile Health Technology and Behavior Change

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Brian D. Duscha, MS …

Brian D. Duscha, MS

1st Annual Duke Preventive Cardiology Symposium
Saturday, April 26, 2014
The overall goal of this activity is to review the latest advancements in the management of lipids in clinical practice, including the new American Heart Association and American College of Cardiology guidelines on lipids announced in November 2013. Topics include learning about evaluation and treatment options in lipids and lipoprotein disorders, as well as focusing on new prevention guidelines, physical activity, nutrition, drug therapies, advanced lipoprotein testing, special patient populations, and new technologies for lifestyle management.

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  • 1. Mobile Health (mHealth) and Behavior Change Brian D. Duscha April 26, 2014 1ST Annual Duke Preventive Cardiology Symposium
  • 2. In the near future, a patient’s next doctor’s appointment may look something like this…… How does my heart look, Doc?
  • 3. Learning Objectives • What is mHealth? • Fun Facts to Support the Increased Popularity of mHealth • How can mHealth be Utilized for Behavior Change and Patient Care? • Case Study/Appropriate Patient • Does it work? Evidence for Efficacy.
  • 4. What is mHealth? mHealth (mobile health) is a general term for the use of mobile phones and other wireless technology in medical care. The most common application of mHealth is the use of mobile phones and communication devices to measure, track and educate patients about their personal health conditions/risk factors. mHealth is especially useful in aiding patients with lifestyle change and monitoring risk factors by self-care. It has the advantage of reaching areas without fixed-line internet access and increasing accessibility because it can be used anywhere at anytime from a wireless device (provided there is coverage!). Can you see my blood pressure and heart rate now?
  • 5. Follow the Trail……..Gaining Public Traction
  • 6. New Google mHealth Hits from 2006 to 2012
  • 7. What Do Physicians Think of mHealth?
  • 8. 2013 Physician Survey
  • 9. How Are People Using Their Apps?
  • 10. Pillars of a Prevention/Healthy Lifestyle Program (mHealth is No Different) Medication Adherence&Apt. Reminders Exercise&Physical Activity WeightLoss& Management Diet&Nutrition PatientEducation Stress Management SmokingCessation ? ?
  • 11. What Else Can mHealth Do For You and Your Patient? • Remote Patient Monitoring of CVD risk factors (BP, BG, Weight, Exercise, Diet, etc.) • Two-way Communication • Chain Management • Data Management • Personalized Intervention for Behavior Change • Long-term Care Strategy to Engage Patient in Self-Care
  • 12. Three (Four)Partners for Sustainable Success Physicians/Care Team Patients Payors Vendors mHealth
  • 13. Current Availability Commercial (OTC) Patient Level (Devices, Apps, websites) • Fit Bit • Jawbone • Valencell • Spark People • Apple • Withings • Nike Institutional Program Level • Improved Patient Outcomes (IPO) • Wellframe • Healarium • Johnson & Johnson • Medtronic • EPIC/EHR
  • 14. Peripheral Devices: “Wearables” and Sensing Technology • Scale • Blood Pressure • Glucometer • Physical Activity
  • 15. Case Report: Mr. Billy Rubin • 63 y.o. T2DM male 5 years post M.I. with PTCA. • Other risk factors include LDL of 170, BMI 31.5, sedentary, HTN and admits to a high salt high fat diet. • Annual H&P shows poorly controlled BG of 135, poor medical adherence and a weight gain of 21 lbs. over last year. • Currently Rx: 20mg Simvastatin, 500mg Metformin b.i.d., 10mg Lisinopril and 80mg aspirin • Mr. Rubin [and his daughter] are concerned with his CAD Hx and wants to improve his risk factors.
  • 16. Mr. Rubin’s Goals • Increase Medical Adherence • Lose 10 lbs in next 3 months • Increase physical activity • Together, you agree that meeting these goals will improve BMI, BG, BP, fitness and lower risk for a CAD event.
  • 17. Mr. Rubin’s mHealth Plan • Eat Better via Daily Awareness/Monitoring of Diet and Education • Caloric Restriction of (-) 400 kcal/day: – ↑ Physical Activity by 100 kcal/day or 2,500 steps over current activity level – ↓ Food Intake by 300 kcal/day • Limit Sodium intake < 1000mg/day • Increase Medical Adherence to 90%
  • 18. Plan for Medical Adherence • Text message reminders will be utilized for prompts to take medications. • A weekly patient self-report encounter will be sent via email asking the patient how many days of the week that they took their medications as prescribed. • Medicine-related educational content will be sent to patient by email that allows them to launch a presentation. • An adherence rate of < 85% will trigger a personal text or call from clinical team.
  • 19. Plan to Increase Exercise • An activity monitoring device (i.e. FitBit tracker) will be utilized by the patient to track data such as “steps taken”, “calories burned”, “distance travelled.” • Educational content will be sent to patient by email that allows them to launch a presentation. • Daily goals for steps and calories burned will be established and tracked for the patient. • An adherence rate < 50% to physical activity instructions will trigger a personal text or call from clinical team.
  • 20. Plan for Weight Management • Patients will be reminded, via text message, to weigh themselves once a week throughout the program. • A digital monitoring device will be used to collect the data. A 5 lb. increase from baseline at any time will initiate a call from the clinical team. • Educational content will be sent to patient by email that allows them to launch a presentation. • Patients will be given a weight goal and progress towards this goal will be presented.
  • 21. Plan for Diet and Nutrition • An electronic food log (e.g. FitBit has an associated food log that can be accessed by website and mobile app) will be utilized by the patient record daily meals. • Text message reminders will be utilized for prompts to complete food logs. • Appropriate educational content will be sent to patient via email that allows them to launch a presentation.
  • 22. Plan to Decrease Blood Pressure • Patients will be reminded, via text message, to self-measure themselves once a week. • A digital monitoring device will be used to collect the data. • An X% increase from baseline at any time will initiate a call from the clinical team. • Patients will be given a blood pressure goal and progress towards this goal will be monitored. • Appropriate educational content will be sent to patient via email that allows them to launch a presentation.
  • 23. Plan to Control Blood Glucose • Patients will be reminded, via text message, to self-measure themselves once a week. • A digital monitoring device will be used to collect the data. • An X% increase from baseline at any time will initiate a call from the clinical team. • Patients will be given a blood glucose goal and progress towards this goal will be monitored. • Educational content will be sent to patient by email that allows them to launch a presentation.
  • 24. You Can See the Pattern…..Assessment, Goals, Plan, Track….Assessment, Goals, Plan, Track…. Advantages • Personalized Medicine • Patient Engagement • Patient Satisfaction (HF data) • Temporal Monitoring • Early Intervention • Potential for EHR Interface • Inclusion of caregivers/family members • Self Care is End Goal !!! Concerns • Patient Burden/Sensory Overload • Device Cost, Compatibility and accuracy • Staffing and Cost • FDA Approved Devices • Security and privacy
  • 25. Does It Work? The Duke Experience • Weight Management • Medical Adherence • Blood Pressure Control
  • 26. Use of mHealth for Weight Management • 120 successful graduates of the DFC program (5% body weight) • Randomized to UC or mHealth for 3 mos. • 1 message/day targeting targeted exercise, healthy diet and monitoring of weight • Average additional weight loss in the mHealth groups after 3 months was approximately 15 pounds, compared with 9.7 pounds in the UC. The American Journal of Medicine (2013) 126, 1002-1009
  • 27. Use of mHealth for Medical Adherence • CVD patients followed for 1 year after hospital discharge • 2 types of voice messaging: Educational and medication refill reminder vs UC • A greater proportion of mHealth patients were adherent to: Clopidogrel (Plavix) (86.8% vs 70.7%; P = .03) Statins (93.2% vs 71.3%; P < .001) ACE/ARB (93.1% vs 81.7%; P = .03) JAMA Intern Med 2014;174(2):186-193.
  • 28. Use of mHealth in Hypertension Control • BP measurements collected via tele-monitoring • 18 mo F/U of 591 HTN patients • Interventions: UC vs 3 telephone based interventions • Intervention trigger alerts were based on a 2-week average home BP of ≥ 135/85 mm Hg for patients without diabetes and ≥ 135/80 mm Hg for patients with diabetes. Circ Cardiovasc Qual Outcomes. 2014;7:269-275
  • 29. BP Control…. • An intervention combining behavioral and medication management significantly improved BP control during the 18-month trial, and these statistically significant improvements were sustained 18 months after trial completion, particularly for patients with inadequate BP control at baseline. • Patients may have realized BP benefits after the trial ended because they were able to effectively execute the behavior changes taught to them in the behavioral management intervention.
  • 30. Who Else Is Doing This? • Mayo Clinic (Healarium) • Boston Health System (Partners HealthCare, Wellframe) • Henry Ford Hospital (J & J)
  • 31. Methods & Results • 90 Day Worksite Health Promotion (n = 152) • Used on-line/Smart Phone platform • Following Assessment: Plans, Tracking, Rewards to Adopt a Healthy Lifestyle Widmer RJ et al. AHJ 2014
  • 32. Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring A. Broderick, Partners HealthCare: Connecting Heart Failure Patients to Providers Through Remote Monitoring, The Commonwealth Fund, January 2013. • Partners HealthCare's programs in home telehealth have been driven by its Center for Connected Health, which has pilot-tested and implemented telemedicine and remote monitoring solutions. The center focuses on practical innovations that can change patient behaviors to realize better clinical outcomes. The center’s Connected Cardiac Care Program has enrolled more than 1,200 patients since its introduction in 2006 and has experienced an approximate 50 percent reduction in heart failure hospital readmission rates overall for enrolled patients. The center estimates the program has generated total cost savings of more than $10 million since 2006. Human factors and social processes have been important in successfully introducing telehealth technology solutions into workflow and patient care. Technology has also had a positive impact on patient activation and engagement in self-care, helping to demonstrate to providers that this new program supports behavior changes that lead to improved care and quality outcomes. Patient Satisfaction • 98% learned more about their HF • 85% felt in control of their health because of the program • 85% reported they were able to gain control over their HF while in the program • 82% reported they were able to avoid the Emergency Room because of the program • 77% reported they will continue to check their weight daily • 64% reported they are confident they can independently mange their HF • 77% would like the providers to offer the program to other HF patients
  • 33. Summary • Use of new mHealth technologies has recently gained interest from both medicine and the lay public. • mHealth has the potential to be a cost effective intervention for promoting patients to make and adhere to healthy lifestyle changes and reduce CVD risk. • It will require an interface between care teams, patients, industry and payors to be successful. • mHealth has the ability to remotely monitor several CVD risks related to lifestyle, detect problems before events occur, communicate & transfer information between patient and care team and serve as a bridge to long-term patient self-care. • Currently, efficacy studies are promising, but further evidence is needed to assess the potential, as well as the challenges, of utilizing mHealth to improve health outcomes.
  • 34. mHealth “Can You Heal Me Now?”