Jennifer Shine Dyer M.D., M.P.H . Chief Medical Advisor eProximiti Duethealth.com Columbus, Ohio May 2011 'What Really Wor...
What Really Works?... <ul><li>Asking a patient: ‘What Really Isn’t Working?’ </li></ul><ul><li>Solid Doctor-Patient Relati...
What Really Isn’t Working? <ul><li>Skipping boluses </li></ul><ul><li>Reduced mindfulness </li></ul>
 
Intensive Basal Bolus Therapy Basal   Insulin Prandial Boluses Insulin 0hr 24hr BG mg/dl
Meal Bolus
Pump download, missed meal boluses
Solid Doctor-Patient Relationship <ul><li>Frequency of communication (email, phone recorded by EMR encounters) </li></ul><...
Hypothesis <ul><li>Weekly  personalized  and  interactive engagement   via texting with the physician will improve meal bo...
Subjects
Methods <ul><li>Weekly Texting Protocol (Thursdays at 5pm) </li></ul><ul><li>Initial greeting message </li></ul><ul><li>Cu...
Results
What Really Isn’t Working? <ul><li>Bolus adherence and glucose checks decreased over time </li></ul><ul><li>Needed motivat...
eproximiti.com duethealth.com
Phone, tablet, and iPod touch versions available for both platforms. Duet
Duet Pilot Data <ul><ul><li>Group  </li></ul></ul><ul><ul><li>3 OBGYN Doctors </li></ul></ul><ul><ul><li>30 Days, asked 60...
What Really Isn’t Working?
BJ Fogg’s Health Behavior Model
Motivating & Rewarding Behavior
Motivating & Rewarding Behavior
Motivation from Support <ul><li>Itunes points </li></ul><ul><li>Social Network support </li></ul>Positive reinforcement fr...
Doctor-Patient Communication, Education, and Literacy Data Mgmt Weekly Texting Reminders Comprehensive Patient Tools
Hypothesis:   Teens that open app daily over 3 months will check glucoses more and improve meal bolus adherence Primary ou...
 
What Really Works?... <ul><li>Mobile tools that focus on what really matters in healthcare: </li></ul><ul><li>-solving pro...
Jennifer Shine Dyer MD, MPH Chief Medical Advisor [email_address] [email_address] eproximiti.com duethealth.com © 2011 ePr...
Dyer Health Care Social Media <ul><li>Blogging </li></ul><ul><li>Podcasts </li></ul><ul><li>Twitter </li></ul><ul><li>Face...
Blogging
Twitter
Facebook
LinkedIn
YouTube
Podcast
Health Literacy: Online Content
mHealth: app development <ul><li>Automated SMS texting </li></ul><ul><li>Personalized features </li></ul><ul><li>Bolus rem...
The United States of Diabetes? Half the Country Could Have Diabetes or Prediabetes by 2020 Predicted cost of $3.35 trillio...
 
External Internet Services: Facilitate initial programming, Facilitate operations of SMS texting delivery and storage
 
Nick Jonas Music Also loves Frappuccinos.
 
Hey Nick! I’ve added you to my address book! Cool. Thanks!  Keep rockin’ Dr. Dyer.
 
 
Dr. Dyer here. Hope the work on the new album is going well.  Can’t wait to hear a sample on your next visit!  February 10th
Hey Nick. How is it going with your boluses?  February 17th
Nick.  Hope the carb counting is going well.  I know u love Frappuccinos!  :)  February 24th
Keep on rocking the boluses, Nick!  See you in a few weeks.  March 3rd
Conversation Monitoring: Tweetdeck Interface
Hypothesis:   Teens that receive weekly personalized automated texts over 3 months will have a significant drop in hgba1c%...
Trigger <ul><li>Make the mobile phone DO SOMETHING at the right time: </li></ul><ul><li>Send push notifications </li></ul>...
Motivate <ul><li>Make the patient WANT to take their medication: </li></ul><ul><li>Utilize Game Mechanics </li></ul><ul><u...
 
Data Management <ul><li>September 21, 2010 </li></ul><ul><li>Sanofi Aventis iPhone/iPod-linked blood glucose meter iBGStar...
Cost Benefit Analysis
<ul><li>Nationwide Children’s Hospital, 7 physicians  </li></ul><ul><li>Academic year (6/1/08-5/31/09) </li></ul><ul><li>1...
<ul><li>~175 inpatient admissions for DKA (involving ~70 different patients) </li></ul><ul><li>~80% related to nonadherenc...
<ul><li>140 inpatient admissions for DKA related to nonadherence </li></ul><ul><li>Average diabetes 3-5 day admission for ...
<ul><li>Reimbursement for texting overhead: </li></ul><ul><li>- 3 cents per text </li></ul><ul><li>- 7 texts per patient p...
<ul><li>Potential savings: </li></ul><ul><li>+$1.4 million per year </li></ul><ul><li>Reimbursement costs for 70 different...
In Conclusion… <ul><li>Challenges remain: </li></ul><ul><li>Privacy </li></ul><ul><li>Insurance reimbursement incentives <...
<ul><li>1922: Pioneer </li></ul><ul><li>The police in Chicago experiment with a radio telephone which broadcast at a frequ...
<ul><li>1940s: Horseback The US Army Signal Corps communicate via radio in the field during wartime.   </li></ul>http://ww...
<ul><li>1959: Commercial Model Reginald Blevins, the Postmaster General of the UK, inaugurates the first radio telephone s...
<ul><li>1972: Portable A model shows off a unit that could dial into telephone systems, displayed at a London exhibition e...
1981: Portable Units <ul><li>The first portable units were really big and heavy.  </li></ul><ul><li>Called transportables ...
<ul><li>1983: Inventor Martin Cooper is credited with developing the first cell phone approved for commercial use. </li></...
1983: DynaTAC 8000X  <ul><li>In 1983 Motorola released the first true mobile phone. </li></ul><ul><li>It weighed about the...
<ul><li>1988: In the Field Frenchman Frank Piccard calls in after taking Gold in the Super G at the 1988 Winter Olympics. ...
1989: GSM Digital Phones <ul><li>In 1989 digital networks lead to the increased use of mobile phones throughout the 90’s. ...
1993: Simon Smartphone <ul><li>First smartphone </li></ul><ul><li>It was created by IBM in 1992 and sold in the US from 19...
1996: Mobile Internet Connection <ul><li>The first popular smartphone was the Nokia Communicator, released in 1996. </li><...
2002: BlackBerry <ul><li>The original Blackberry had a monochrome (black and white) screen and was used for email, surfing...
Evolution of the Blackberry
<ul><li>2006: Camera Phones Palestinian students at a Ramallah University photograph physicist Steven Hawking, who has arr...
<ul><li>2007: Text is Next Morgan Pozgar, 13, of Claysburgh, Pennsylvania, competes in the LG National Texting Championshi...
<ul><li>2008: BlackBerry </li></ul><ul><li>In the last election, Barack Obama used his BlackBerry to arrange his appointme...
http://www.time.com/time/photogallery/0,29307,1636836_1721987,00.html#ixzz15BoqFZg8 2008: The iPhone 3G Steve Jobs unveils...
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  • Reduced mindfulness, diabetes happens every meal and there isn’t a choice about it. It sucks.
  • Frequent contact (intensive) as evidenced by DCCT trial and more physiologic basal bolus therapy.
  • A lot of visits (good doc patient relationship) but they weren’t helping as noted by skipped bolues. I’m an academic and have removed some details of methods.
  • One app with 20-30 specialty modules within it so duet becomes an educational software platform. Giving me an automated platform that I needed.
  • Good patients record/engage, and bad patients don’t record/engage. Not checking glucoses.
  • Motivation, Ability, Trigger….engagement theory
  • In conclusion…
  • If your not solving a problem, you’re irrelevant.
  • At the current rate, it is projected that by 2020 that 40% of nation will be obese. One in five health dollars will be spent to address the consequences of obesity.
  • Email – too passive
  • The Fitbit accurately tracks your calories burned, steps taken, distance traveled and sleep quality. The Fitbit contains a 3D motion sensor like the one found in the Nintendo Wii. The Fitbit tracks your motion in three dimensions and converts this into useful information about your daily activities. You can wear the Fitbit on your waist, in your pocket or on undergarments. At night, you can wear the Fitbit clipped to the included wristband in order to track your sleep. Anytime you walk by the included wireless base station, data from your Fitbit is silently uploaded in the background to Fitbit.com. Integrates with Google Health, Facebook, Twitter
  • 15-20% of total inpatient discharges ~1000 in the year
  • Rate limiting factors: physician time and overhead. Incentives determine how time is spent. Average salary ~$200,000 per year (senior and junior faculty).
  • 2 stanford talkdyer

    1. 1. Jennifer Shine Dyer M.D., M.P.H . Chief Medical Advisor eProximiti Duethealth.com Columbus, Ohio May 2011 'What Really Works': Diabetes and Mobile Health in Medical Practice
    2. 2. What Really Works?... <ul><li>Asking a patient: ‘What Really Isn’t Working?’ </li></ul><ul><li>Solid Doctor-Patient Relationship </li></ul>
    3. 3. What Really Isn’t Working? <ul><li>Skipping boluses </li></ul><ul><li>Reduced mindfulness </li></ul>
    4. 5. Intensive Basal Bolus Therapy Basal Insulin Prandial Boluses Insulin 0hr 24hr BG mg/dl
    5. 6. Meal Bolus
    6. 7. Pump download, missed meal boluses
    7. 8. Solid Doctor-Patient Relationship <ul><li>Frequency of communication (email, phone recorded by EMR encounters) </li></ul><ul><li>Frequency of clinic visits </li></ul><ul><li>Press Ganey scores </li></ul>
    8. 9. Hypothesis <ul><li>Weekly personalized and interactive engagement via texting with the physician will improve meal bolus mindfulness and reduce hgba1c % within 3 months (at next clinic visit) in teens with type 1 diabetes. </li></ul>
    9. 10. Subjects
    10. 11. Methods <ul><li>Weekly Texting Protocol (Thursdays at 5pm) </li></ul><ul><li>Initial greeting message </li></ul><ul><li>Customized question unique to each patient’s interests </li></ul><ul><li>Questions specific to adherence </li></ul><ul><li>Conclusion message </li></ul>
    11. 12. Results
    12. 13. What Really Isn’t Working? <ul><li>Bolus adherence and glucose checks decreased over time </li></ul><ul><li>Needed motivation </li></ul><ul><li>Needed reminders </li></ul><ul><li>Needed more support </li></ul>
    13. 14. eproximiti.com duethealth.com
    14. 15. Phone, tablet, and iPod touch versions available for both platforms. Duet
    15. 16. Duet Pilot Data <ul><ul><li>Group </li></ul></ul><ul><ul><li>3 OBGYN Doctors </li></ul></ul><ul><ul><li>30 Days, asked 60 patients – 100+ participated </li></ul></ul><ul><ul><li>Results </li></ul></ul><ul><ul><li>Feb-March 2011 </li></ul></ul><ul><ul><li>Doctors handed out all materials in 7 days </li></ul></ul><ul><ul><li>By 10 th day, 20% of patients opened app more than 9 times </li></ul></ul><ul><li>Physician Feedback </li></ul><ul><li>Andrew Bokor, MD (OB/Gyn): </li></ul><ul><li>” I don’t think there is any way it won’t improve quality of women’s health care and outcomes” </li></ul>
    16. 17. What Really Isn’t Working?
    17. 18. BJ Fogg’s Health Behavior Model
    18. 19. Motivating & Rewarding Behavior
    19. 20. Motivating & Rewarding Behavior
    20. 21. Motivation from Support <ul><li>Itunes points </li></ul><ul><li>Social Network support </li></ul>Positive reinforcement from friends & family. Motivation + rewards. Using Peer & Family Reinforcement
    21. 22. Doctor-Patient Communication, Education, and Literacy Data Mgmt Weekly Texting Reminders Comprehensive Patient Tools
    22. 23. Hypothesis: Teens that open app daily over 3 months will check glucoses more and improve meal bolus adherence Primary outcome variable: ∆ hgba1c% change over 3 months between control and intervention group Study Enrollment Control Group: Standard of care routine office contacts Intervention Group: Weekly personalized automated texts Routine Office Visit (3 months) <ul><li>Routine hgba1c % </li></ul><ul><li>Psychology exit survey </li></ul><ul><li>Routine hgba1c % </li></ul><ul><li>Psychology intake survey </li></ul>Real-time conversation monitoring for safety <ul><li>All contacts recorded (both texting and routine office contacts) </li></ul>50 patients 50 patients
    23. 25. What Really Works?... <ul><li>Mobile tools that focus on what really matters in healthcare: </li></ul><ul><li>-solving problems </li></ul><ul><li>-compassion </li></ul>
    24. 26. Jennifer Shine Dyer MD, MPH Chief Medical Advisor [email_address] [email_address] eproximiti.com duethealth.com © 2011 eProximiti, Inc. All rights reserved
    25. 27. Dyer Health Care Social Media <ul><li>Blogging </li></ul><ul><li>Podcasts </li></ul><ul><li>Twitter </li></ul><ul><li>Facebook </li></ul><ul><li>Linkedin </li></ul><ul><li>Youtube </li></ul><ul><li>Health Literacy: Online Content </li></ul><ul><li>mHealth </li></ul>
    26. 28. Blogging
    27. 29. Twitter
    28. 30. Facebook
    29. 31. LinkedIn
    30. 32. YouTube
    31. 33. Podcast
    32. 34. Health Literacy: Online Content
    33. 35. mHealth: app development <ul><li>Automated SMS texting </li></ul><ul><li>Personalized features </li></ul><ul><li>Bolus reminder system </li></ul>
    34. 36. The United States of Diabetes? Half the Country Could Have Diabetes or Prediabetes by 2020 Predicted cost of $3.35 trillion (10% of total healthcare spending) The United States of Diabetes: Challenges and Opportunities in the Decade Ahead , UnitedHealth Group’s (NYSE: UNH) Center for Health Reform & Modernization, November 23, 2010: http://www.unitedhealthgroup.com/newsroom/news.aspx?id=36df663f-f24d-443f-9250-9dfdc97cedc5
    35. 38. External Internet Services: Facilitate initial programming, Facilitate operations of SMS texting delivery and storage
    36. 40. Nick Jonas Music Also loves Frappuccinos.
    37. 42. Hey Nick! I’ve added you to my address book! Cool. Thanks! Keep rockin’ Dr. Dyer.
    38. 45. Dr. Dyer here. Hope the work on the new album is going well. Can’t wait to hear a sample on your next visit! February 10th
    39. 46. Hey Nick. How is it going with your boluses? February 17th
    40. 47. Nick. Hope the carb counting is going well. I know u love Frappuccinos! :) February 24th
    41. 48. Keep on rocking the boluses, Nick! See you in a few weeks. March 3rd
    42. 49. Conversation Monitoring: Tweetdeck Interface
    43. 50. Hypothesis: Teens that receive weekly personalized automated texts over 3 months will have a significant drop in hgba1c% Primary outcome variable: ∆ hgba1c% change over 3 months between control and intervention group Study Enrollment Control Group: Standard of care routine office contacts Intervention Group: Weekly personalized automated texts Routine Office Visit (3 months) <ul><li>Routine hgba1c % </li></ul><ul><li>Psychology exit survey </li></ul><ul><li>Routine hgba1c % </li></ul><ul><li>Psychology intake survey </li></ul>Weekly conversation monitoring on Dyer iphone for safety <ul><li>All contacts recorded (both texting and routine office contacts) </li></ul>50 patients 50 patients
    44. 51. Trigger <ul><li>Make the mobile phone DO SOMETHING at the right time: </li></ul><ul><li>Send push notifications </li></ul><ul><li>Add calendar events with alarms </li></ul><ul><li>SMS </li></ul><ul><li>CALL </li></ul><ul><li>(Email) </li></ul>
    45. 52. Motivate <ul><li>Make the patient WANT to take their medication: </li></ul><ul><li>Utilize Game Mechanics </li></ul><ul><ul><li>Imagine piloting a nanobot through the bodies of fictional cancer patients, destroying cancer cells in your path, battling bacterial infections, and managing side effects. This is the Re-Mission game, developed for adolescents and young people with cancer, that hopelab.org believe will help them develop a positive attitude, learn about their cancer and has been shown to improve adherence . – Roberts </li></ul></ul><ul><li>Competition </li></ul><ul><li>Social </li></ul>
    46. 54. Data Management <ul><li>September 21, 2010 </li></ul><ul><li>Sanofi Aventis iPhone/iPod-linked blood glucose meter iBGStar and free management app </li></ul><ul><li>To be submitted to FDA in near future </li></ul>
    47. 55. Cost Benefit Analysis
    48. 56. <ul><li>Nationwide Children’s Hospital, 7 physicians </li></ul><ul><li>Academic year (6/1/08-5/31/09) </li></ul><ul><li>1,425 different patients with type 1 & type 2 diabetes </li></ul><ul><li>4,057 diabetes outpatient clinic visits </li></ul><ul><li>Average of 200 diabetic patients per physician </li></ul>
    49. 57. <ul><li>~175 inpatient admissions for DKA (involving ~70 different patients) </li></ul><ul><li>~80% related to nonadherence </li></ul>
    50. 58. <ul><li>140 inpatient admissions for DKA related to nonadherence </li></ul><ul><li>Average diabetes 3-5 day admission for DKA costs ~$10,000 </li></ul><ul><li>Total costs of $1.4 million per year </li></ul>
    51. 59. <ul><li>Reimbursement for texting overhead: </li></ul><ul><li>- 3 cents per text </li></ul><ul><li>- 7 texts per patient per week </li></ul><ul><li>- 21 cents/patient/week </li></ul><ul><li>- $42 per week per physician taking care of average 200 diabetic patients </li></ul><ul><li>-~$11 per patient per year </li></ul><ul><li>Reimbursement for physician time per week spent on texting: </li></ul><ul><li>- 5% of clinical activity </li></ul><ul><li>- 5% of salary </li></ul><ul><li>- $10,000 per year </li></ul><ul><li>- $200 per week </li></ul><ul><li>- $1 per patient per week to physician taking care of average 200 diabetic patients for each texting encounter </li></ul><ul><li>Total reimbursement (overhead + time): </li></ul><ul><li>- ~$65 to physician per patient per year </li></ul>
    52. 60. <ul><li>Potential savings: </li></ul><ul><li>+$1.4 million per year </li></ul><ul><li>Reimbursement costs for 70 different patients: </li></ul><ul><li>-$4,550 per year </li></ul>
    53. 61. In Conclusion… <ul><li>Challenges remain: </li></ul><ul><li>Privacy </li></ul><ul><li>Insurance reimbursement incentives </li></ul><ul><li>Medicine is slow to change </li></ul><ul><li>… but we’ve come a long way, anything (even mHealth) is possible! </li></ul>
    54. 62. <ul><li>1922: Pioneer </li></ul><ul><li>The police in Chicago experiment with a radio telephone which broadcast at a frequency just above the AM radio band. </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389493,00.html#ixzz15BlbmzVi
    55. 63. <ul><li>1940s: Horseback The US Army Signal Corps communicate via radio in the field during wartime. </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389499,00.html#ixzz15Bm7vMUI
    56. 64. <ul><li>1959: Commercial Model Reginald Blevins, the Postmaster General of the UK, inaugurates the first radio telephone service for motorists. </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389495,00.html#ixzz15BmJ5SQn
    57. 65. <ul><li>1972: Portable A model shows off a unit that could dial into telephone systems, displayed at a London exhibition entitled, &quot;Communications Today, Tomorrow and the Future.&quot; </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389496,00.html#ixzz15BmSawMk
    58. 66. 1981: Portable Units <ul><li>The first portable units were really big and heavy. </li></ul><ul><li>Called transportables or luggables. </li></ul><ul><li>They were so large mainly because of the size of the battery that they were housed in their own briefcase. </li></ul>Source: http://www.galaxyphones.co.uk/mobile_phones_history09.asp
    59. 67. <ul><li>1983: Inventor Martin Cooper is credited with developing the first cell phone approved for commercial use. </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389497,00.html#ixzz15BmcHsNI
    60. 68. 1983: DynaTAC 8000X <ul><li>In 1983 Motorola released the first true mobile phone. </li></ul><ul><li>It weighed about the same as a bag of sugar and had a battery life of only 8 hours </li></ul><ul><li>It cost $3,995 and sold over 300,000 units in the first year alone. </li></ul>Source: http://www.i4u.com/article421.html
    61. 69. <ul><li>1988: In the Field Frenchman Frank Piccard calls in after taking Gold in the Super G at the 1988 Winter Olympics. </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389498,00.html#ixzz15BnJuNUs
    62. 70. 1989: GSM Digital Phones <ul><li>In 1989 digital networks lead to the increased use of mobile phones throughout the 90’s. </li></ul><ul><li>The vast majority of phones were black or dark grey with aerials and small screens. </li></ul>Source: http:// www.motorola.com
    63. 71. 1993: Simon Smartphone <ul><li>First smartphone </li></ul><ul><li>It was created by IBM in 1992 and sold in the US from 1993. </li></ul><ul><li>It was a mobile phone, basic computer, pager and fax machine. </li></ul><ul><li>Cost was $899 </li></ul>
    64. 72. 1996: Mobile Internet Connection <ul><li>The first popular smartphone was the Nokia Communicator, released in 1996. </li></ul><ul><li>The phone looked like a normal (but very big) phone on the outside but opened to reveal a full QWERTY keyboard. </li></ul><ul><li>The Communicator was able to connect to the Internet (VERY slowly...) </li></ul>
    65. 73. 2002: BlackBerry <ul><li>The original Blackberry had a monochrome (black and white) screen and was used for email, surfing the Internet, fax and phone services </li></ul><ul><li>BlackBerry is manufactured by a Canadian company – RIM (Research in Motion) </li></ul>
    66. 74. Evolution of the Blackberry
    67. 75. <ul><li>2006: Camera Phones Palestinian students at a Ramallah University photograph physicist Steven Hawking, who has arrived to give a lecture. </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389508,00.html#ixzz15BoNhxy4
    68. 76. <ul><li>2007: Text is Next Morgan Pozgar, 13, of Claysburgh, Pennsylvania, competes in the LG National Texting Championship at the Roseland Ballroom in New York. </li></ul>http://www.time.com/time/photogallery/0,29307,1636836_1389509,00.html#ixzz15BoeYHNS
    69. 77. <ul><li>2008: BlackBerry </li></ul><ul><li>In the last election, Barack Obama used his BlackBerry to arrange his appointments, surf the internet, and keep in touch with his team while he was on the road. </li></ul>http://www.thetechherald.com/article.php/200908/2972/Mitnick-Obama-s-BlackBerry-can-be-breached
    70. 78. http://www.time.com/time/photogallery/0,29307,1636836_1721987,00.html#ixzz15BoqFZg8 2008: The iPhone 3G Steve Jobs unveils the latest generation of his revolutionary product. The 3G is faster and less expensive than its predecessor with larger screen for video.
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