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  • Did a bit of ‘spreading’
  • To demonstrate this, let me first describe two models for developing interventions. On the one side, there is the “top-down” approach where content is generated by experts and experts evaluate the information. This is the model that I have been working under and I believe most scientists think about when developing interventions. The strength to this method is that techniques are rigorous but it is also slow. In contrast, another model of intervention development could be called “crowd-sourcing”. In a crowd-sourced solution content is generated by the crowd and evaluated by the crowd. This of course creates a very fast system but it is difficult to know if the information is accurate or the intervention useful. This model, however, is increasingly gaining favor among technologists and thus it is something we scientists must be mindful of. For example, who uses Encyclopedia Britannica’s website? OK, who uses Wikipedia? Wikipedia is powerful because it is crowd-sourced and we must be mindful of that if we want to find way to get technology to use behavioral science.
  • We have been exploring this in the MILES project, which stands for Mobile interventions for lifestyle exercise at Stanford. As stated earlier, the study is an NIH-funded challenge grant. We are currently finalizing development of our three applications. We plan to start our pilot study in January 2011.
  • The charge for this study is to develop theoretically meaningful smartphone apps for mid-life and older adults that will increase physical activity & decrease sedentary behavior concurrently. As I was suggesting before, a key design element for all of our applications is the passive assessment of physical activity and sedentary behaviors as this allows us to provide just-in-time feedback that can be framed with different mechanisms for behavior change.
  • So that’s exactly what I took the lead on conducting and was just at the mHealth Summit last week in DC presenting. Specifically, we conducted a validation study of Android phones, the phones we are using in our intervention trial, among 15 mid-life & older adult men & women. We had our participants engage in 12 laboratory-based activities, such as walking on the treadmill, for 3-4 minutes each and then compared the values we gathered from the Android phones to the highly validated Actigraph.
  • Results revealed that, in fact, the three phones were giving very similar data to the Actigraph. The above is just one of the three phones but the other phones were similar. We then utilized this regression equation to calculate appropriate cut-points for classifying sedentary behavior and moderate/vigorous intensity physical activity for real-time classification via the phones.
  • First, here are the three “glance-able” displays for the applications. Although the information gathered is identical, minutes engaged in sedentary behavior and MVPA, the way we are displaying it is quite different in each app. For the cognitive app, we wanted to frame the information relative to goals as this model assumes that behavior change occurs through active goal-setting and problem-solving through an active “cognitive” process. For the “affect” app, we utilizing a bird “avatar” as the method of tracking your activity. In this app, as you are more active, the bird flies faster, is happier, and becomes more playful. The idea here is that we believe a person would map the bird’s mood, particularly as it feels happier to their own mood and thus create a link up between being more active and feeling better. Finally, for the social app, you will notice that there are multiple stick figures on the home screen. With this design, the idea here is that a person will be motivated to be more active based on the level of activity of other participants in the study via social norm motivations. These glance-able displays set up the differences between the three apps but now I’m going to show you some more specific elements in each.
  • We have been exploring this in the MILES project, which stands for Mobile interventions for lifestyle exercise at Stanford. As stated earlier, the study is an NIH-funded challenge grant. We are currently finalizing development of our three applications. We plan to start our pilot study in January 2011.

Transcript

  • 1. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment Plan Saturday, March 10, 2012 7:00 AM - 4:30 PM DoubleTree by Hilton Hotels
  • 2. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment PlanMade possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. Thetrademark Exercise is Medicine is used by permission from the American College of Sports Medicine.
  • 3. Promoting Healthy Lifestyles in Real World Clinical Settings: Moving Beyond the Barriers. Randa M. Kutob, MD, MPH Exercise is Medicine Conference March 10, 2012 Department of Family and Community Medicine University of Arizona, College of Medicine rkutob@email.arizona.edu
  • 4. Disclosures• I have no financial or other conflicts of interest to disclose.
  • 5. What Are We Here For?• Review data on obesity, physical activity, and diabetes in the U.S.• Explore provider barriers to lifestyle counseling• Examine the evidence for what works• Share ways to put more lifestyle change into our practices
  • 6. What I Hope You Will Get Out of ItJust one idea to implement in your practiceto promote physical activity and lifestylechange.
  • 7. But First… A Quiz http://hp2010.nhlbihin.net/portion/
  • 8. Do You Know How Food Portions Have Changed in 20 Years? National Heart, Lung, and Blood Institute Obesity Education Initiative
  • 9. COFFEE 20 Years Ago Today Coffee Mocha Coffee(with whole milk and sugar) (with steamed whole milk and mocha syrup) 45 calories How many calories 8 ounces are in todays coffee?
  • 10. COFFEE 20 Years Ago Today Coffee Mocha Coffee(with whole milk and sugar) (with steamed whole milk and mocha syrup) 45 calories 350 calories 8 ounces 16 ounces Calorie Difference: 305 calories
  • 11. Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to walk in order to burn those extra 305 calories?* *Based on 130-pound person
  • 12. Calories In = Calories Out If you walk 1 hour and 20 minutes, you will burn approximately 305 calories.* *Based on 130-pound person
  • 13. TURKEY SANDWICH20 Years Ago Today 320 calories How many calories are in today’s turkey sandwich?
  • 14. TURKEY SANDWICH20 Years Ago Today 320 calories 820 calories Calorie Difference: 500 calories
  • 15. Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to ride a bike in order to burn those extra calories?* *Based on 160-pound person
  • 16. Calories In = Calories Out If you ride a bike for 1 hour and 25 minutes, you will burn approximately 500 calories.* *Based on 160-pound person
  • 17. Scope of the Problem Obesity Trends* Among U.S.Adults, BRFSS, 1990, 2000, 2010 (*BMI 30, or about 30 lbs. overweight for 5’4” person) Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/DDTSTRS/default.aspx .
  • 18. Obesity Trends* Among U.S. Adults BRFSS, 1985 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14%
  • 19. Obesity Trends* Among U.S. Adults BRFSS, 1986 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14%
  • 20. Obesity Trends* Among U.S. Adults BRFSS, 1987 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14%
  • 21. Obesity Trends* Among U.S. Adults BRFSS, 1988 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14%
  • 22. Obesity Trends* Among U.S. Adults BRFSS, 1989 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14%
  • 23. Obesity Trends* Among U.S. Adults BRFSS, 1990 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14%
  • 24. Obesity Trends* Among U.S. Adults BRFSS, 1991 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19%
  • 25. Obesity Trends* Among U.S. Adults BRFSS, 1992 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19%
  • 26. Obesity Trends* Among U.S. Adults BRFSS, 1993 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19%
  • 27. Obesity Trends* Among U.S. Adults BRFSS, 1994 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19%
  • 28. Obesity Trends* Among U.S. Adults BRFSS, 1995 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19%
  • 29. Obesity Trends* Among U.S. Adults BRFSS, 1996 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19%
  • 30. Obesity Trends* Among U.S. Adults BRFSS, 1997 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% ≥20%
  • 31. Obesity Trends* Among U.S. Adults BRFSS, 1998 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% ≥20%
  • 32. Obesity Trends* Among U.S. Adults BRFSS, 1999 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% ≥20%
  • 33. Obesity Trends* Among U.S. Adults BRFSS, 2000 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% ≥20%
  • 34. Obesity Trends* Among U.S. Adults BRFSS, 2001 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  • 35. Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  • 36. Obesity Trends* Among U.S. Adults BRFSS, 2003 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  • 37. Obesity Trends* Among U.S. Adults BRFSS, 2004 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  • 38. Obesity Trends* Among U.S. Adults BRFSS, 2005 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 0%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 39. Obesity Trends* Among U.S. Adults BRFSS, 2006 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 40. Obesity Trends* Among U.S. Adults BRFSS, 2007 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14 15%–19% 20%–24% 25%–29% ≥30%
  • 41. Obesity Trends* Among U.S. Adults BRFSS, 2008 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 42. Obesity Trends* Among U.S. Adults BRFSS, 2009 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 43. Obesity Trends* Among U.S. Adults BRFSS, 2010 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  • 44. County-level Estimates of Diagnosed Diabetes among Adults aged ≥ 20 years: United States 2008Age-adjusted ranks based on age-adjusted percent of diabetes Above median rank Below median rank Not above median rank or below median rank www.cdc.gov/diabetes
  • 45. County-level Estimates of Leisure-time Physical Inactivity among Adults aged ≥ 20 years: United States 2008 Age-adjusted percent Quartiles 0 - 23.2 23.3 - 26.2 26.3 - 29.1 > 29.2 www.cdc.gov/diabetes
  • 46. FRENCH FRIES20 Years Ago Today 210 Calories How many calories are in 2.4 ounces today’s portion of fries?
  • 47. FRENCH FRIES20 Years Ago Today 210 Calories 610 Calories 2.4 ounces 6.9 ounces Calorie Difference: 400 Calories
  • 48. Maintaining a Healthy Weight is a Balancing Act Calories In = Calories Out How long will you have to walk leisurely in order to burn those extra 400 calories?* *Based on 160-pound person
  • 49. Calories In = Calories OutIf you walk leisurely for 1 hour and 10 minutesyou will burn approximately 400 calories.* *Based on 160-pound person
  • 50. Walking in the U.S.• U.S. Men-5,340 steps• U.S. Women-4,912 steps (Bassett, 2010)• Amish men-18,425 steps• Amish women-14,196 steps (Bassett, 2004)
  • 51. Obesity, Diabetes, and Physical Inactivityin the U.S., Arizona, and Pima County United States Arizona Pima CountyObesity 33.8 % (2008) 24.3 % (2010) 23.8 % (2010)Diabetes 8.3 % (2011) 8.1 % (2010) 7.0 % (2008)Physical 25.0 % (2008) 22.9 % (2010) 19.7 % (2008)Inactivity Centers for Disease Control and Prevention: National Diabetes Surveillance System. http://apps.nccd.cdc.gov/DDTSTRS/default.aspx .
  • 52. Scope of the ProblemDiabetes and Prediabetes 18.8 million with diabetes Diagnosed Diabetes 7.0 million undiagnosed Undiagnosed+79.0 million w/prediabetes Diabetes Prediabetes______________________ Those Unaffected= 104.8 million!!!! Centers for Disease Control and Prevention. National Diabetes Fact Sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011.
  • 53. BUT…Only 1/3 of those with prediabetes receivedprovider advise about it in the past year!(Geiss, 2010)
  • 54. What are Practicing Docs/ProvidersDoing? A Survey of Our Practice (n=62)Gordon JS, Thomson C, Kutob R, Burns KD, Byron D, Marquis A, & Cunningham J.Practices, attitudes, self-efficacy, and perceived barriers for preventing and treatingobesity in the primary care clinic. Poster presented at the Research Frontiers inNutritional Sciences Conference, February 29 – March 1, 2012, Tucson, AZ.
  • 55. What Does the Literature Say?• Time• Lack of materials• Lack of resources• Lack of confidence in counseling skills• Reimbursement• Concerns about effectiveness(Kushner 1995, Kolasa 2010)
  • 56. So What Can We Do?If primary care physicians did all thepreventive services recommended by theUSPSTF, we would spend 7.4 hours out ofan 8-hour day doing them! (Yarnall 2003)
  • 57. Exercise Matching Game Calories Burned in 30Activity minutes• Walking • a. 140 calories• Yoga/stretching • b. 220 calories• Bicycling • c. 295 calories• Jumping Rope • d. 145 calories• Yard Work • e. 165 calories• Weight Training • f. 90 calories• Swimming• Basketball • g. 110 calories• Jogging • h. 255 calories • i. 325 calories
  • 58. Table 2. From the Surgeon General’s Vision for a Healthy and Fit Nation52. Kolasa K M , Rickett K Nutr Clin Pract 2010;25:502-509Copyright © by The American Society for Parenteral and Enteral Nutrition
  • 59. Training, Effectiveness, and Confidence: Know What Works• High intensity (face to face at least once a month for 3 months)• Frequent contact• Self-monitoring (keeping food diaries and activity records)• Nutrition education and meal planning (portion size and not skipping meals)• Control of the stimuli that activate eating• Goal setting• Social support• Increasing physical activity
  • 60. More Is BetterAt 2 years:• Usual Care: minus 1.7 kg• Brief Lifestyle Counseling: minus 2.9 kg• Brief Lifestyle Counseling plus Meal Replacement: minus 4.6 kg (Wadden, 2011)
  • 61. Think About How to Deliver theMessage: Eliciting Explanatory Models• “How do you feel about your weight?”• “How do you feel your weight affects your health?”• Think about Stages of Change• Use Motivational Interviewing techniques• Help your patient set realistic, specific goals• Ask about barriers• Telling patients to exercise without a specific intervention does not work!
  • 62. Time and Teams: Don’t Do It All Yourself• Registered Dieticians• Medical Assistants• Nurses• Promotoras• Referrals to community programs
  • 63. The UA Health Network’s Clinical Weight Loss Program
  • 64. Community Resources• YMCA’s: up to 100% financial assistance available• Diabetes Prevention: YMCA and United Healthcare• Community Centers: – E.g., Kino, Drexel Heights, Catalina, JCC, Ellie Townes Flowing Wells, John Valenzuela Youth Center, Littletown, Robles Ranch• Parks and Recreation• City Pools(Byron, UA Family Medicine Residency Program, 2011)
  • 65. Reimbursement • If you can, collect data to show key stake holders the value of what you do • Or share with the data that already exists24.7 Billion Dollars!!!! (Ormand, 2011)
  • 66. Don’t Do It In the Same Way: Families United:Familias UnidasGroup Office Visits forDiabetes Prevention• Twelve, 2-hour sessions• Adults, ages 18-70, with any diabetes risk factor (e.g., hypertension, hype rtriglyceridemia, etc.) were eligible• Participants identified one support person, age 14-70, to accompany them
  • 67. Have Fun Doing It !Have Fun Doing It!
  • 68. The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:Advisory Board:Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community HealthContinuumTaz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education InstituteMaureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.Pima County Medical Society - Steve Nash, JD, Executive Director.University of Arizona Section of Endocrinology, Diabetes and Hypertension- CraigStump, M.D., PhD, Professor.University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Centerfor Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.Creative Team:Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.M2Design: Graphic Design - Michael Drabousky.Dupont Videography: Video Recording & Editing - John Dupont.Sonora Communications: Computing, Networking, Internet Services Gene Cooper.
  • 69. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment Plan Saturday, March 10, 2012 7:00 AM - 4:30 PM DoubleTree by Hilton Hotels
  • 70. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment PlanMade possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. Thetrademark Exercise is Medicine is used by permission from the American College of Sports Medicine.
  • 71. Eric Hekler, Ph.D. Assistant ProfessorSchool of Nutrition and Health Promotion Arizona State University
  • 72. Outline My background State of technology State of the science Promising commercial technologies Coming soon…
  • 73. My background Clinical Health Psychologist, Rutgers Postdoc – Stanford University Focus: The use of technologies for health behavior change ACSM Committees:  SHI-Behavioral Health Committee  EIM Family Website development  EIM Committee member for identifying evidence- based practices
  • 74. Technology-focused projects Mobile Interventions for Lifestyle Eating and Exercise at Stanford (MILES) study Exploring the influence of intentions when playing Exergames The CHAT Trial - Focused on promoting physical activity by telephone delivered either by a human or automated counselor The Stanford Healthy Neighborhood Discovery Tool CHART-2: Intervention to increase physical activity using PDAs
  • 75. Disclaimer I will be discussing many different technologies. I am in no way affiliated with any of the corporations mentioned and I am NOT endorsing them in any way. I use them more as illustrative examples.
  • 76. Outline My background State of technology State of the science Promising commercial technologies Coming soon…
  • 77. What has changed? Technology offers opportunities for behavior change that were near impossible10 years ago Key players  Widespread use of cell phones (and smartphones)  “Cloud” computing  Cheap wireless sensors with APIs  Algorithms  Information development models  Social Networking
  • 78. http://thenextweb.com/mobile/2011/02/02/the-shocking-numbers-behind-cellphone-usage-infographic/
  • 79. What is the cloud?
  • 80. Algorithms Powerful data analytic techniques  Machine learning, data mining, system identification Used in a variety of contexts  Focused Search (i.e., Google)  Activity classification  “Recommender” systems  Persuasion Profiles  Mood classification via voice, writing style, etc.
  • 81. “2024”“2014”
  • 82. Development Models Expert-sourced  Crowd-sourced  Content generated by  Content generated by “experts” “crowd”  Information evaluated  Information evaluated by experts by crowd  Rigorous but slow  Fast but inaccurate?  www.britannica.com  www.wikipedia.org
  • 83. Wired, July 2009, Quantified Self
  • 84. Outline My background State of technology State of the science Promising commercial technologies Coming soon…
  • 85. Technology delivery channels Exergames Text messaging (SMS) Web pages Interactive voice response systems Wearable sensors Smartphones Social media Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Brassington, Hekler, et al. in press
  • 86. Exergames Exergames  Can promote light to moderate intensity PA Much less work on sustained use Some research exploring best practicesBarnett, Cerin, Baranowski, 2011; Chen, Hekler, King, underreview
  • 87. Text messaging Some efficacy for general health promotion  Less work on PA in particular, but promising Most used SMS as just one component Work best if appropriately timedFjeldsoe, B. et al. 2009; Franklin, et al. 2006;Norman, Kolodziejczyk, Hekler, & Ramirez, under review
  • 88. Web pages  “Small but statistically significant effects”  Efficacious interventions tended to:  Compared to wait-list control  Focused on shorter-timeline  Key problem  Sustained adherenceCugelman, Thelwall, & Dawes, 2011; Webb, Joseph, Yardley, & Michie, 2010;Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Neve, Collins, et al. 2010
  • 89. Interactive voice response Very few studies, but very promising results Comparable to human intervention Even for promoting 18m maintenance Norman, Kolodziejczyk, Hekler, & Ramirez, under review; AC King, et al. 2007; King, Hekler, et al. under review
  • 90. Wearable sensors Lots of devices out there, with some evidence starting to be collected Pedometers (particularly accelerometer- based such as Omron’s devices) BodyMedia best evidence for weight loss Others just starting to be researched  Fitbit, Phillips Direct Life Norman, Kolodziejczyk, Hekler, & Ramirez, under review; Brassington, Hekler, et al. in press
  • 91. Smartphones Very limited evidence but popular topic Will be reporting some preliminary efficacyNorman, Kolodziejczyk, Hekler, & Ramirez, under review;Brassington, Hekler, et al. in press
  • 92. Social media  Very limited evidence, very popular topic  Research finds health advice given  One study, StepMatron, used Facebook app and pedometer to motivate PA  Results found increased check-ins on steps when using Facebook compared to not  Much more work is neededNorman, Kolodziejczyk, Hekler, & Ramirez, under review; J. A. Greene, Choudhry,Kilabuk, & Shrank, 2011; Foster, Linehan, Kirman, Lawson, & James, 2010
  • 93. Outline My background State of technology State of the science Promising commercial technologies Coming soon…
  • 94. Happtique Healthcare-APP-bouTIQUE Focused on categorizing health apps Exploring ways to build evidence into apps practice
  • 95. Popular Smartphone apps RunKeeper iMapMyFitness Nike+GPS Hundred PushUps All in Yoga HD Monumental
  • 96. Lots of new devices Nike Fuelband Striiv Jawbone UP
  • 97. Outline My background State of technology State of the science Promising commercial technologies Coming soon…
  • 98. Lots of new stuff being tested Many health researchers  UCSD- Smart Trial Human Computer Interactions  CHI Conference  Personalinformatics.org
  • 99. Introduction Mobile Interventions for Lifestyle Exercise and Eating at Stanford (MILES) NHLBI-funded Challenge Grant (10/09 – 08/12)  PI- King, 1RC1HL099340-01 Status: Ran preliminary pilot with 36 older adults; iterated on design and now running second trial Collaborators: Abby King, Tom Robinson, Matt Buman, Lauren Grieco, Frank Chen, Jesse Cirimele, Beth Mezias, Banny Banerjee, Martin Alonso
  • 100. Purpose Develop theoretically meaningful smartphone apps for midlife & older adults Physical activity & sedentary behavior Passively assess PA & SB Provide just-in-time feedback for behavior change
  • 101. Activity Algorithm Validation N=15, Men & Women, Mean Age=55 12 laboratory-based activities 3-4 min each Hip- and pocket-worn Android phones Compared to Actigraph & Zephyr Bioharness Hekler et al, 2010, November
  • 102. Results Comparison of Phone to Actigraph "Counts" Minute-level "counts" 1000Phone AUC m/s3 800 600 y = 0.09x + 55.1 400 R² = 0.83 200 0 0 2000 4000 6000 8000 10000 12000 Actigraph "counts" Hekler et al, 2010, November
  • 103. The “Apps” Control:mTrack mSmiles mConnect Calorific King, Hekler, et al. April, 2012, Hekler et al. 2011
  • 104. Very Preliminary Results Difference in LMPA across the intervention compared to control 90Physical Activity Differences min/day of Light/Moderate 80 ** compared to Control 70 60 ** 50 40 30 ns 20 10 0 mSmiles mConnect mTrack King, Hekler, et al. April, 2012
  • 105. EIM initiatives in the works EIM Family-focused website EIM evidence-based practices
  • 106. Thank you for inviting me! Eric Hekler ehekler@asu.edu Designing Health Lab @ASU Twitter: @ehekler
  • 107. References Barnett, A., Cerin, E., & Baranowski, T. (2011). Active video games for youth: a systematic review. Journal of Physical Activity & Health, 8(5), 724-737. Retrieved from http://www-ncbi-nlm-nih-gov.ezproxy1.lib.asu.edu/pubmed/21734319 Brassington, G., Hekler, E. B., Cohen, Z., & King, A. C. (2011). Health Enhancing Physical Activity. Handbook of Health Psychology. Mahwah, New Jersey: Lawrence Erlbaum Associates Publishers. Chen, F. X., Hekler, E. B., & King, A. C. (2012). Designing Health Messages: Framing Exergames for Exercise Improves Duration of Use. submitted for publication2. Cugelman, B., Thelwall, M., & Dawes, P. (2011). Online Interventions for Social Marketing Health Behavior Change Campaigns: A Meta-Analysis of Psychological Architectures and Adherence Factors. Journal of Medical Internet Research, 13(1), 84- 107. doi:e17 10.2196/jmir.1367 Fjeldsoe, B. S., Marshall, A. L., & Miller, Y. D. (2009). Behavior change interventions delivered by mobile telephone short-message service. American journal of preventive medicine, 36(2), 165-73. American Journal of Preventive Medicine. doi:10.1016/j.amepre.2008.09.040 Foster, D., Linehan, C., & Kirman, B. (2010). Motivating physical activity at work: using persuasive social media for competitive step counting. Proceedings of the 14th …. Retrieved from http://dl.acm.org.ezproxy1.lib.asu.edu/citation.cfm?id=1930510
  • 108. References Franklin, V. L., Waller, A., Pagliari, C., & Greene, S. A. (2006). A randomized controlled trial of Sweet Talk, a text-messaging system to support young people with diabetes. Diabetic Medicine, 23(12), 1332-1338. Hekler, E B, Buman, M. P., Haskell, W. L., Rosenberger, M., & King, A. C. (n.d.). Validity of Android-Based Mobile Phones as Assessment Devices of Physical Activity. mHealth Summit. Washington, DC. King, A C, Friedman, R., Marcus, B., Castro, C., Napolitano, M., Alm, D., & Baker, L. (2007). Ongoing physical activity advice by humans versus computers: The community health advice by telephone (CHAT) trial. Health Psychology, 26(6), 718-727. doi:10.1037/0278-6133.26.6.718 Neve, M. J., Collins, C. E., & Morgan, P. J. (2010). Dropout, Nonusage Attrition, and Pretreatment Predictors of Nonusage Attrition in a Commercial Web-Based Weight Loss Program. Journal of Medical Internet Research, 12(4), 81-96. doi:e69 10.2196/jmir.1640 Neve, M., Morgan, P. J., Jones, P. R., & Collins, C. E. (2010). Effectiveness of web- based interventions in achieving weight loss and weight loss maintenance in overweight and obese adults: a systematic review with meta-analysis. Obesity Reviews, 11(4), 306-321. doi:10.1111/j.1467-789X.2009.00646.x Webb, T. L., Joseph, J., Yardley, L., & Michie, S. (2010). Using the Internet to Promote Health Behavior Change: A Systematic Review and Meta-analysis of the Impact of Theoretical Basis, Use of Behavior Change Techniques, and Mode of Delivery on Efficacy. Journal of Medical Internet Research, 12(1). doi:e4 10.2196/jmir.1376
  • 109. The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:Advisory Board:Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community HealthContinuumTaz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education InstituteMaureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.Pima County Medical Society - Steve Nash, JD, Executive Director.University of Arizona Section of Endocrinology, Diabetes and Hypertension- CraigStump, M.D., PhD, Professor.University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Centerfor Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.Creative Team:Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.M2Design: Graphic Design - Michael Drabousky.Dupont Videography: Video Recording & Editing - John Dupont.Sonora Communications: Computing, Networking, Internet Services Gene Cooper.
  • 110. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment Plan Saturday, March 10, 2012 7:00 AM - 4:30 PM DoubleTree by Hilton Hotels
  • 111. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment PlanMade possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. Thetrademark Exercise is Medicine is used by permission from the American College of Sports Medicine.
  • 112. Cynthia Thomson, PhD, RD Director Canyon Ranch Center for Prevention and Health Promotion Exercise is Medicine Planning Committeefittucson.org
  • 113.  32 local restaurants Minimum 3 menu items meeting “healthy” criteria < 700 calories <1000 mg sodium < 15 grams fat NutritionHub
  • 114.  Post information in a visible location ◦ Place strategically: Shared with key staff in your office ◦ Personal wellness ◦ Wellness ambassadors Write scripts for healthy behaviors Follow-up, monitor and reward progress Visit fittucson.org
  • 115. The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:Advisory Board:Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community HealthContinuumTaz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education InstituteMaureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.Pima County Medical Society - Steve Nash, JD, Executive Director.University of Arizona Section of Endocrinology, Diabetes and Hypertension- CraigStump, M.D., PhD, Professor.University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Centerfor Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.Creative Team:Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.M2Design: Graphic Design - Michael Drabousky.Dupont Videography: Video Recording & Editing - John Dupont.Sonora Communications: Computing, Networking, Internet Services Gene Cooper.
  • 116. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment Plan Saturday, March 10, 2012 7:00 AM - 4:30 PM DoubleTree by Hilton Hotels
  • 117. The Only Prescription with Unlimited Refills Every Patient, Every Visit, Every Treatment PlanMade possible by funding from the Centers for Disease Control and Prevention and the Pima County Health Department. Thetrademark Exercise is Medicine is used by permission from the American College of Sports Medicine.
  • 118. Tucson, March 10, 2012
  • 119. Talk Outline1. What are group visits?2. How do you organize and schedule a group visit?3. How do you bill & document a group visit?4. Apply group visit techniques to exercise
  • 120. What Kinds of Patients Benefit Most from GroupVisits? High Risk Patients, Namely ◦ Those patients who have an increased risk for “both” high resource utilization and poor outcomes ◦ Obese patients are certainly at high risk for both
  • 121. High Risk Groups Diabetes Obesity Tobacco users Asthma Cardiovascular disease (CVD) Dyslipidemia Depression Total joint replacements Frail elderly HIV/AIDS
  • 122. What Are Group Visits?
  • 123.  Maximize educational time by working with 6-30 patients at a time Many patients prefer group visits Group visits offer a billable service Any medical provider can offer group visits ◦ Doctors, nurses, PA, pharmacists, mental therapists, dieticians, etc.-- a physician and a dietician can even do a visit together ◦ Attendance drops if the primary physician is not involved
  • 124.  Annual visits share information and reach set targets for the group’s diagnosis (Lipids, BP) A series of 2-4 visits focused upon weight loss or tobacco cessation Longitudinal group visits can substitute many individual doctor visits (e.g., type 2 diabetes over 6-10 visits)
  • 125.  Class provides information to a group Group visit must gather information and document it in the patient record, label an assessment, and note a plan Group visit is a billable service, a class usually is NOT a billable service ◦ Billing information will follow ◦ You must spend a moment of one-on-one time to clarify the subjective, objective, assessment, and plan for the visit. 60-90 seconds will suffice
  • 126.  NO “right model,” just the one that works for you and your patients The model you use is based upon ◦ The goals for your patients ◦ Your patients diagnoses ◦ Your reimbursement needs ◦ Office space you have available
  • 127.  Improve clinical outcomes Increase your productivity by about 15% to 25% Improve both patient and provider satisfaction Lower total health care costs
  • 128.  Group visits help many patients succeed in making lifestyle changes: ◦ Quitting tobacco use ◦ Food monitoring improves diet compliance ◦ Monitoring and promoting activity encourages exercise
  • 129.  Share more information in less time Improve clinical outcomes Improve patient satisfaction for many patients Save money on the cost of providing care Enhance reimbursement (~20%) Improve provider satisfaction This is a rare Win/Win/Win/Win/Win opportunity
  • 130. Organizing & Scheduling Group Visits (This section is addressed in your handout in detail)
  • 131. “By doing just a little every day, I can gradually let the task completely overwhelm me.” --Ashleigh Brilliant
  • 132.  Schedule a session 8-12 weeks in advance Schedule 2-3 MA/LPN level providers for the first 15-30 minutes to collect data Reserve a room! Prepare material in advance Prepare chart note forms in advance
  • 133. Group Visit Organization Organization brings order Disorganization produces CHAOS Some chaos will occur
  • 134. “In science as in love, too much concentration on technique can often lead to impotence.” --P.L. Berger
  • 135. Allow 4 hrs total time for a group visit with 20-30 patients/session: 2 hrs group time & 2 hrs preptime (5 pts/hr of your time) ◦ 1 hour to prepare didactic materials and to coordinate with your staff ◦ 1 hour for chart reviews prior to the visit ◦ 1/2 hour for 2-3 nurses to collect data and for the provider to document specific plans ◦ 1 hour to share information with the group ◦ 1/2 hour for wrap-up
  • 136.  Choose a group visit size that reflects your style, patient population, and group visit room You could see 10 patients during a total of 2 hours of physician time for a 1-hour group visit session ◦ Allow 30 min chart review, 30 min to prepare materials, and 1 hour for the session (again at least 5 pts/hour of MD time
  • 137.  30 minutes to collect patient data, meet individually, and complete medical record notes 15 minutes for the group to address their concerns to me and each other 45 minutes to introduce didactic material and interact 30 minutes to answer questions, plus time to write prescriptions, and meet individual needs Actual physician time varies; I encourage you to finish on time!
  • 138.  4-6 weeks prior, mail/e-mail a letter to selected patients in your practice advertising dates for you next group visit (See sample letter) The letter encourages them to call and enroll for the group visit Have your receptionist call 1 week later to encourage enrollment (See sample phone call script) Anticipate 40-50% enrollment (if the primary physician invites own patients to attend; 5-15% enrollment if primary writes the letter, and another provider offers the group visit)
  • 139.  Addresses key targets for the specific diagnosis If you have a registry of high risk cohort patients, this is very easy If your charts lack cohort specific targets, the first review can be lengthy, but critically important Once a template is built for the chart review, nurse/MA can add data for physicians review
  • 140.  First visit, during registration forms must be signed (I strongly recommend confidentiality and HIPAA forms), patients should be registered and fees collected Thereafter, register, collect co-payment or normal appointment fee, and begin data collection Be prepared for a wave all arriving at once ◦ You can’t have them line up like a usual visit
  • 141.  I agree to meet with a group of patients and my doctor. I have the choice to be seen by my physician in this group, or individually Like any doctor’s appointment, I agree to be responsible for the bill or co-payment associated with this doctor’s visit Signature: ___________________
  • 142.  I agree to keep all information regarding other patients at these visits private, and agree not to disclose any information regarding other patients in these group visits I will respect others’ privacy - ok to discuss what you have learned in these sessions, but don’t mention anyone’s name outside this group! Signature: _________________
  • 143.  Receptionist should mention this issue when they register for the appointment Signed HIPAA Disclosure Form Essential ◦ Share with your HIPAA compliance officer (Example) ◦ During a Group Visit, it is possible that some of my personal health information will be disclosed. For example, at a Group Visit for Tobacco Cessation, it might be assumed that everyone attending uses tobacco. Discussions may occur regarding personal health information during a group visit. I have been notified of this potential disclosure and I wish to participate in a group medical visit. I realize that I have the option of being seen individually. Signature___________________
  • 144.  Arrive on time Register Find a chair and complete subjective aspect of the SOAP note Then meet with the nurse Next meet with the doctor Return to chair
  • 145.  Maximum 3-4 minutes/ pt (sees 10 pts/30 min) Medical Record (EMR or paper) New progress note completed. MD may have already made comments from chart review Scale, BP cuff, monofilament for foot exam, peak flow meter, etc, etc Subjective and objective part of the note completed at this station Physician will complete the note and sign the progress note
  • 146.  Maximum 45-90 seconds one-on-one, face-to-face ◦ Signed HIPAA disclosure essential ◦ Clarify assessment with the patient, (You smoke, it is harmful, & I advise you to stop using tobacco) ◦ Get permission to share questions and answers with the group ◦ Might include starting a new medication and the risks/ benefits with that Rx ◦ Put issues to address on the clip board ◦ Private issues can be addressed at an individual follow up visit (a recent headache)
  • 147.  Have a typed, fill in the blank note for your chart reviews (examples to follow) Fill in targets and recent labs prior with the chart review Choose targets you want to reach for the note Leave subjective and objective data for a nurse to collect, let your patients fill out the subjective part of the chart Your chart note documentation determines your billing level
  • 148. Documentation and Billing Examples
  • 149. Group Visits are Only Intended for Established Patients New patients should initially be seen individually Otherwise, the potential patient interactions and billing aspects may become very complicated
  • 150.  HPI: Subjective  Objective Any new angina. Any new signs CHF ◦ Wt, BP, recent lipid (SOB, edema, wt increase?) profile, FBS or HbgA1C  Assessment ROS: Recent activity level ◦ CAD; At target? Yes/No ◦ No activity ◦ Moderate 2-3 times / wk  Plan ◦ Moderate 4-6 times / wk * vigorous <4 times ◦ Treat and follow lipids /wk vigorous 4 or more x/ wk ◦ ASA daily (or other Rx) ◦ Encourage activity and healthy Recent type fat intake diet ◦ Most common fat intake ◦ Review med options: risks, benefits, effects Produce serving intake ◦ Mange HTN & glycemia ◦ Less than 2 cups daily ◦ >50% of this 90-minute visit in ◦ 2-3 cups daily counseling ◦ 4 or more cups daily Past Med Hx: (See chart) Meds: (See med chart) Tobacco Use:
  • 151.  99213, with 4 parts to the history, a brief exam, and decision making regarding a complex problem, with a stable patient and no therapy changes for a diagnosis of CAD 99214, with 4 parts to the history, 2 past med parts, and 2 ROS parts, a brief exam, and a CAD patient requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change
  • 152.  HPI: Subjective  Objective (dated)Recent hypoglycemia? ◦ Wt, BP, recent HbgA1C, lipids, urinary(shaky, jittery, light-headed) microalbumin, creatinine Fatigue? Freq urination? ◦ Foot and eye exams ROS: Activity Level  Assessment ◦ No activity ◦ Type 2 Diabetes ◦ Moderate 2-3 times / wk (controlled/uncontrolled) ◦ Moderate 4-6 times / wk vigorous  Plan <4 times / wk vigorous 4 or more ◦ HgbA1C Rx reviewed x / wk ◦ ASA daily Produce servings intake ◦ Encourage activity ◦ Less than 2 cups daily ◦ Encourage healthy diet ◦ 2-4 cups daily ◦ Review med options: ◦ 5 or more cups daily risks, benefits, side effects (Including ace-inhib.) Past Med Hx: (See chart) ◦ Manage Meds: (Include ASA qd; see flow lipids, HTN, proteinuria, feet, retina sheet) ◦ >50% of this 90-minute visit in Tobacco Use: counseling
  • 153.  99213, with 4 parts to the history, a brief exam, and decision making regarding a complex problem, with a stable patient and no therapy changes for a diagnosis of TYPE 2 DIABETES 99214, with 4 parts to the history, 2 past med parts, and 2 ROS parts, a brief exam, and a TYPE 2 DIABETIC patient requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change
  • 154. SAMPLE TOBACCO CESSATION PROGRESS NOTEName: _______________________________ Date:____________ID #: _______________________________HPI: Subjective (at least 4 questions)Years you have smoked? _____ Average cigarettes per day? _____ Howmany times have you tried to quit? _____Number tobacco pack years? ____________Hx recent heartburn? yes noHx smoker’s cough/coughing? yes noHx sinus problems? yes noAny specific issues you want addressed at this visit with the group?___________________________________________________________________ROS: (at least 2 questions)– Has your activity level been recently limited by breathing issues?– Any chest pain with exercise?– Any problems with insomnia?Past Med Hx: (See chart for details)Meds: (Include ASA qd; see flow sheet)
  • 155. TOBACCO USE: PROGRESS NOTE (cont)Objective: – Wt __________ BP __________ BMI ________ RR ________ – Peak flow today ___________Assessment: (Tobacco abuse, 305.1) Other related diagnoses? _____________________Plan: – Quit date planned – Behavioral options to quit reviewed – Medication options reviewed. Risks, benefits, and side effects discussed and questions answered – Rx ________________________________________ – Additional plan _________________________________Billing: (circle one) 99213 99214
  • 156. Tobacco Abuse Visit Billing Options 99213, stable patient with tobacco abuse, evaluation includes a history with 4 questions and ROS with two questions (may or may not include a brief exam), and decision making regarding a complex problem, receiving education, updated information 99214, Tobacco abuse with other complicated medical problems and in addition to the above, you address a treatment plan that entails some risk and benefit regarding the additional problems ◦ Usually a patient requiring a change in therapy with documentation of a risk benefit discussion related to that therapy change in addition to tobacco cessation, such as a change in blood pressure therapy during this same visit
  • 157.  You are not limited to taking insurance An example, I offer a Ten Years Younger Group Visit Course ◦ 4-12 group sessions ◦ Body composition measures taken pre & post ◦ Initial nutrition evaluation ◦ Individual fitness evaluation pre & post ◦ They have the option of weekly trainer sessions at a gym and get a 8-12 week gym membership ◦ Price varies from $500-1200 mostly depending upon amount of trainer time
  • 158. Group Visit Details
  • 159.  Do not rely upon time Rely upon the complexity of the diagnosis and your documentation Spend a few moments of individual time with each patient, briefly review the data collected, their diagnosis, and ensure their individual questions are addressed with the group Adding extra diagnoses beyond overweight will help for insurance coverage of this visit
  • 160.  Call coverage, especially inpatient and obstetrical call Minimize patient “NO SHOWS” with: ◦ Reminder calls 1-2 days prior “Your MD expects you at this visit!” ◦ Advertise guest speakers or cooking demonstrations ◦ If the patient’s physician isn’t going to lead the group visit a physician letter encouraging the session improves attendance
  • 161.  Mid afternoon for seniors Early evenings for working adults Tuesday, Wednesday, and Thursdays appear the most popular days Saturday mornings work for some groups (about 1/3-1/4 of those willing to participate in group visits)
  • 162.  Exercise topics Weight loss Tobacco cessation Food choices (Adding foods, increase fiber intake, changing type fat intake, reducing fat intake) Medications and supplements Lab testing topics Shopping, dining, and cooking skills Understanding lipid levels and targets Stress management
  • 163.  Space? Managed care environment? Staff support? Inertia?
  • 164.  Not all clinics are set-up to provide group visits with a lecture hall room Try using the waiting room, works for smaller groups Hospitals, community clinics, and religious centers will often provide space for free to a physician and their group to meet
  • 165.  Horse-shoe shape works well Back corners used for nurse evals ◦ Curtain for privacy optional Put handout materials by the entry/exit door Have a cart with blood pressure cuffs, charts, materials, extra pens, etc. Consider table for tea, healthy snacks, or for cooking demos
  • 166.  You need an administrative champion ◦ Offer to track your success as a pilot for other clinicians Every group visit tracked to date has resulted in better satisfaction, lower cost to provide care, and better outcomes Many managed care companies encourage and promote group visits
  • 167.  Organize your staff in advance Anticipate several people during the first ~ 30 minutes and one person to stay throughout the visit Teach your staff to encourage group visits
  • 168.  This is a real factor It takes energy to save energy Are you fed up with the status quo yet? How dissatisfied to you need to become to be willing to make things better? ◦ Why not make this better before things get even worse ???
  • 169.  Finally, you can get paid to educate your patients during a group visit and: ◦ Improve outcomes ◦ Improve patient satisfaction ◦ Reduce health care expenses ◦ Enhance provider satisfaction and provider compensation
  • 170. The Only Prescription with Unlimited RefillsSPECIAL THANKS TO:Advisory Board:Carondelet Health Network - Donna Zazworsky, RN, CCM, FAAN, VP Community HealthContinuumTaz Greiner, Obesity Prevention Program Manager. Carondelet Diabetes Education InstituteMaureen MacDonald, MEd, MSW, LMSW, Carondelet Diabetes Education Coordinator.Carondelet Medical Group - Michael Connolly, DO, Internal Medicine.Children’s Medical Center of Tucson - Jessica Schultz, M.D., Pediatrician.Pima Heart - Charles Katzenberg, M.D., FACC Cardiologist.Pima County Medical Society - Steve Nash, JD, Executive Director.University of Arizona Section of Endocrinology, Diabetes and Hypertension- CraigStump, M.D., PhD, Professor.University of Arizona Center For Physical Activity and Nutrition - Scott Going, PhD, Professor.University of Arizona Mel & Enid Zuckerman College of Public Health - Canyon Ranch Centerfor Prevention and Health Promotion - Cynthia Thomson, PhD, RD, Professor.Creative Team:Centrum Medical Communications: Medical Education & Marketing - Laurel Rokowski, RN.M2Design: Graphic Design - Michael Drabousky.Dupont Videography: Video Recording & Editing - John Dupont.Sonora Communications: Computing, Networking, Internet Services Gene Cooper.