Medical grand rounds 9.22.2011
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  • Total number of activated personal health record users.
  • Total number of sessions per user and time for each session.

Medical grand rounds 9.22.2011 Medical grand rounds 9.22.2011 Presentation Transcript

  • Utilizing three important screens to improve health: the computer, cell phone and television James Kahn MD Professor of Medicine, UCSF AHRQ HS017784; NIH grants RR024369 and MH088341 and DA032057
  • Overview
    • Provide a framework for mHealth and internet based research
    • Review active research projects
    • Discuss new models that develop from the research projects
    • Conclusions
    • A glimpse into the future
  • Conclusions
    • New tools are necessary to improve health care
    • Personal Health Records (PHRs) are intended to improve self management
    • We deployed a PHR integrated into our EMR for patients receiving care at the HIV/AIDS clinic at SFGH and were surprised by the ready acceptance of the technology and its dissemination
    • Text messaging is another important tool to deliver health care
    • mHealth applications have local, national and international implications
  • Three themes for our work
    • Improve health and reduce the digital divide through technology development, adoption and utilization
    • Empower patients through innovative use of technology
    • Provide a platform for research that emphasizes operational excellence and implementation science
  • IOM How to Improve Care
    • “ Improvements in care cannot be achieved by further stressing current systems of care. The current systems cannot do the job. Trying harder will not work.”
    • IOM 2001: Crossing the Quality Chasm
  • The Case for Improvement
    • Hip Fracture
    • Atrial Fibrillation
    • Community Acquired Pneumonia
    • Urinary Tract Infection
    • Diabetes
    • Colorectal Cancer
    • Congestive Heart Failure
    • Hypertension
    • Coronary Artery Disease
    • 22.8%
    • 24.7%
    • 39.6%
    • 48.7%
    • 45.6%
    • 53.5%
    • 63.9%
    • 64.7%
    • 68.8%
    McGlynn, et al. NEJM 2003 348:2635-2645 Outpatients receive only 55 % of recommended care
  • Do vs. know Transformative technology Real world Incentives for the process Hypothetical growth with knowledge and resources Pay for results Empower Consumers Do Know
  • Sources used to find information
    • The future is already here, it's just not evenly distributed
    • William Gibson
    • The Economist 2003
  • Information Systems Financial Information Demographics Notes, Immunizations Labs, Medications Images Consults, Reports Important Documents Financial Information Demographics Diagnosis, Immunizations Labs, Medications Images Consults, Reports Important Documents EMRs populated with data from “reliable” sources PHRs populated with data from patient sources Systems owned Patient owned
  • Definition--Personal Health Record
    • A longitudinal record of individual health
    • The PHR can be accessed and populated, from electronic sources, patients or devices
    • Information in the PHR is owned or at the least shared by the patient
    • The PHR is meant to move along with the patient no matter where they are located or their connection to a specific health plan or organization
  • Self management support vs. shared decision-making: a new dynamic
    • Shared decision-making is the process for involving patients in decision making and planning
    • Self-management support is the broader process of engaging and activating patients to more fully participate in care
  • Patient Self-Management
    • “ Patients with chronic conditions self-manage their illness. This fact is inescapable. Each day, patients decide what they are going to eat, whether they will exercise, and to what extent they will consume prescribed medications.”
    • Tom Bodenheimer, et al 2002 JAMA 288(19); 2470
  • Why Develop a PHR?
    • Promotes self management by providing information that is up-to-date and understandable
    • Reduce the Digital Divide through more egalitarian access to information
    • Improve the experience of care
    • Improve the health of populations
    • Reduce per capita costs of health care
    • Health literacy is vital to understand the information to create an action plan based on the information
    Berwick, D. M et al. (2008). Health Aff 2008: 27: 759-769
  • HIV is a chronic diseases
    • Dangerous chronic illness with available, effective treatment
    • Treatment is difficult and lasts over years and decades
    • Treatment requires sustained behavior change on part of patient
    • Gap between knowledge and outcomes
    These statements apply to HIV and apply to: Hypertension Diabetes Congestive Heart Failure Asthma / COPD Obesity The data elements change, but the strategy and the tools for improved outcomes is consistent and includes: patient education, behavior change, monitoring, medication adherence and engagement with an extended health community
  • Architecture for myHERO at SFGH
  • Total number of PHR users Kahn J S et al. JAMIA 2010;17:224-228 ©2010 by BMJ Publishing Group Ltd
  • Number of sessions /user / time Kahn J S et al. JAMIA 2010;17:224-228 ©2010 by BMJ Publishing Group Ltd
  • Goal of the project-AHRQ
    • Our central hypothesis is that a secure PHR that combines meaningful information, web-based tools for support and reminders for patients will provide a substantial opportunity to promote self-management and will lead to improved health outcomes
    • To test our hypothesis we are performing a randomized controlled study to evaluate the biologic outcomes between persons randomly assigned to full use PHR compared with persons assigned to deferred access.
  • Study Design Investigators: Joan Hilton Urmimala Sarkar Dean Schillinger David Thom Ricardo Munoz Neda Ratanawongsa Screen all clinic patients to participate Obtain consent from all willing participants Control group—deferred myHERO access but with internet training, free email address Experimental group –immediate myHERO access with internet training, free email address Provide access to all participants Randomize 12-months 12-months
  •  
  •  
  • Mental Health Diagnoses
  • Substance use Diagnoses
  • Observations from Recruitment
    • Patients who are “full” users are very excited about seeing their personal health information.
      • “ This is the coolest thing I have ever seen”
      • “ This is truly amazing”
    • Deferred users are not thrilled with their assignment but there is no differential drop-out rates
  • Accessibility Issues
    • Font Size—we made the Font Bigger
    • Radio Button Size—increased the size
    • Mouse Use
    • “ Next Page” vs. “Submit”—now “DONE”
    • User names and passwords
      • Patients now write these down
      • New tool to reset passwords online
  • What worked and what did not
    • Patients will use the PHR survey system.
    • Patients want accurate data
    • Patients are receiving appropriate care especially related to ART.
    • Good anti-HIV responses are common with available medications
  • Technology Skill Acquisition
    • We provided 50% with their first email account.
    • We taught 85% of patients how to use the internet.
    • Terms:
      • cursor,
      • field,
      • user name,
      • password,
      • address bar,
      • enter,
      • scroll and
      • link.
    • A series of “How to”
      • Make a capital letter;
      • Use numbers and letters;
      • Locate a cursor;
      • Copy something;
      • Paste something;
      • Scroll down or around on the page;
      • Make the @ sign;
      • Enter something;
      • Go to a website
  • Information Sheet
    • Visit this website to take your surveys: myhero.sfdph.org
    • Your myHERO username: _______________
    • Your myHERO password: ___________________
    • Your email website: __________________________
    • Your email username: ______________________
    • Your email password: _________________________
    • Please keep this in a safe place & don’t share your usernames or passwords with anyone.
    • For free computer classes, please go to the main San Francisco public library on Tues’ 5:30 PM-7:30 PM, Wed’s 5:30 PM-7:30 PM, Thurs’ 5:30 PM-7:30 PM, and Saturdays 10:00-1:00 PM with Project Read.
  • Bridging technology
    • Not all patients have equal access to the internet but nearly everyone has a cell phone and these devices are becoming more common, less expensive and more powerful with a growing number of applications
      • Help drive patients to the internet when there is new information of value
      • Alerts and reminders
      • Inform patients of new information and disasters
      • Improve management for health and wellness
      • International implications for health care
  • All Whites (75%) All Blacks (59%) English-Speaking Hispanics (80%) 73%* of the population reports using the internet or email. Here is a breakdown of use among different online groups. (shown as a percentage of population online) 18-29 Years Old (90%) 30-49 Years Old (85%) 50-64 Years Old (70%) 65+ Years Old (35%) No High School Degree (44%) College Graduates (91%) <$30K Income (53%) >$75K Income (95%) Men (73%) Women (73%) *Source: Pew Internet & American Life Survey, May 2008. http://www.pewinternet.org ** This statistic comes from the Pew Internet Project’s Latinos Online data, collected June-October, 2006. High School Graduates (63%) Urban (74%) Rural (63%) Suburban (77%) Spanish-Dominant Hispanics (32%)** 12-17 Years Old (94%)
  • 55%* of the population reports using a high-speed connection (e.g., DSL, cable, wireless) when accessing the internet from home. Here is a breakdown of use among different online groups. (shown as a percentage of population using a high-speed connection from home) Whites (56%) Blacks (41%) English-Speaking Hispanics (55%) 18-29 Years Old (69%) 30-49 Years Old (68%) 50-64 Years Old (49%) 65+ Years Old (19%) No High School Degree (29%) College Graduates (78%) <$30K Income (31%) >$75K Income (82%) Men (57%) Women (52%) High School Graduates (39%) Urban (56%) Suburban (59%) Rural (38%) *Source: Pew Internet & American Life Survey, May 2008. http://www.pewinternet.org 12-17 Years Old (66%)
  • Whites (79%) Blacks (73%) English-Speaking Hispanics (80%) 78%* of the population reports owning a cell phone. Here is a breakdown of use among different online groups. (shown as a percentage of population owning a cell phone) 18-29 Years Old (86%) 30-49 Years Old (87%) 50-64 Years Old (77%) 65+ Years Old (55%) No High School Degree (59%) College Graduates (89%) <$30K Income (63%) >$75K Income (92%) Men (78%) Women (78%) High School Graduates (73%) Urban (75%) Suburban (81%) Rural (73%) *Source: Pew Internet & American Life Survey, may 2008. http://www.pewinternet.org 12-17 Years Old (71%)
  • Mobile Phones In 2007, worldwide mobile telephone subscriptions reached 3.3 billion -- equivalent to half the global population 26 years after the first cellular network was launched 100% mobile phone penetration in the US by 2013
  • Specific SMS Functions
    • Reminders to patients
      • Immunizations
      • Appointments
      • Pap smears
      • Mammograms
      • Medication Adherence
    • Notifications for patients
      • Lab results are available for viewing
      • Clinician follow-up is expected
      • Medication Refills should be requested
      • Targeted behavioral interventions for: Depression intervention, Tobacco Abatement, Anxiety control
  • Study Design Investigators: Joan Hilton, Monica Gandhi Team members: Tracy Nunnery Lindsay Halperin, Kelly Bryant Screen all clinic patients to participate Obtain consent from all willing participants Control group—No SMS messages SMS messages for medication adherence and lifestyle Randomize Run in SMS texting check
  • Automating SMS --closing the loop
  • It is complex…
  • Total Screened = 476
    • Enrolled = 99 patients (20.8%)
    • Types of Phones
      • 33 Smartphone
        • 8 iphone
        • 4 blackberry
        • 21 other full keyboard,
        • web enabled phones
      • 62 Standard Phone
    • Phone Providers  
      • 48 Metro PCS (48%)
      • 14 AT&T
      • 12 T Mobile
      • 6 Sprint
      • 8 Verizon Wireless
      • 4 Virgin Mobile
      • 2 Boost Mobile
  • Ineligible patients
    • 487 ineligible screening events (69 twice)
        • 127 Undetectable VL
        • 76 Not on ARV meds
        • 60 Patient reports adherence support not needed
        • 62 No cell phone (11% of all screened patients)
        • 154 Other (Do not text/Not interested /Language)
    • “ The most exciting experiments are the ones that do not go as expected”
  • Cell and Computer Use
    • “ How often do you use your cell phone for text messaging?”
    • Always/Often 84%
    • Sometimes 9%
    • Rarely/Never 6%
    • Number with an e-mail accounts 88% (N=87)
    • Number with a myHERO (PHR) account 40% (N=39)
  • SMS messaging for medications
    • 9,957 messages for medications adherence and conditions were assigned by the system and 9719 (98%) were sent. Errors occurred during unexpected system maintenance.
    • We studied a “closed-loop” response system and more than 57% of the messages had a message reply.
    • 94% of the messages that had a successful reply also generated a positive response i.e. “Did this help you? Reply Yes or No”
  • SMS messaging for medications
    • 70% remained at daily reminders
    • 20% opted for messages 3 times a week
    • 10% opted for messages once a week
  • New model of work Managing a clinic population Patients who can use technology to help manage their care Patients who need human navigators to help with technology and care Patients who need human navigators to help with care and are not ready for technology Patients who totally self manage their care Patients who need more assistance Patients who need assistance Patients who need human navigators to help with care and are not ready for technology
  • Push or Pull Information
    • Is it better to push information to patients and hope there is uptake?
    • Is it better to let patients pull information when they are ready and for its uptake?
    • Does it matter?
    • Why not do both?
      • Technology makes this
      • a viable approach
  • Utilizing three important screens to improve health: the computer, cell phone and television
  • Conceptual approach
    • Systems pushing information to patients and clinicians (Ex: PHRs and lab results)
    • Patients pushing information to systems and others (Ex: Bluetooth devices, social networks)
    • Systems pulling information from patients (Ex: GPS awareness; run on flu medications)
    • Patients pulling information from systems (Ex: patients able to query databases)
  • New horizons for SMS Help
    • What would you like us to do?
    • Make or change a visit?
    • Refill meds or list my meds?
    • Check labs?
    • Receive advice now?
    • Get a call back?
    3. Check Labs
    • What labs?
    • T-cells
    • HIV Viral load
    • Liver studies
    • Cholesterol studies
    • Diabetes labs
    1. T-cells Your last 3 T-cells were: 520 on September 24, 2010 310 on March 15, 2010 421 on November 1, 2009 Who are you? Will you send your ID? JSK56789!
  • Telehealth
    • Clinician perspective telehealth is already deployed for diagnostic and routine follow-up in Dermatology, Radiology, Psychiatry, Ophthalmology.
    • Clinician extenders and save patient expenses
    • Encourage connection to the health system
    • Involve a group of caregivers or care providers efficiently---especially remote connections to areas of great expertise
  • An example of merging technology
        • Good ideas are not adopted automatically. They must be driven into practice with courageous patience.
        • Admiral Rickover
  • Conclusions
    • New tools are necessary to improve health care
    • Personal Health Records (PHRs) are intended to improve self management
    • We deployed a PHR integrated into our EMR for patients receiving care at the HIV/AIDS clinic at SFGH and were surprised by the ready acceptance of technology its dissemination
    • Text messaging is another important tool to deliver health care
    • mHealth applications have local, national and international implications
  • Partners for our work
    • Commonwealth Foundation
    • Blue Shield Foundation
    • NIMH, AHRQ, NCRR
    • Microsoft
    • Avanade
    • Boomcomms
    • California Health Care Foundation
  • Medical Informatics Team 09/22/11 Supported by AHRQ HS017784; NIH: RR024369 and MH088341 NIDA R01DA032057 Jackie So Kelly Bryant Lindsey Halperin Skip Leasure Mitch Roberts Tracy Nunnery Olivia Chang Raeni Miller Robert Thawley Joan Hilton Monica Gandhi Adam Carrico Leslie Wilson
  • Research requires change
        • It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change
        • ---Charles Darwin
  • Thank you and Questions Jim Kahn 415-699-1118 [email_address] http://profiles.ucsf.edu/ProfileDetails.aspx?Person=4999786
  • Jerry Garcia
    • “ Somebody has to do something, and it's just incredibly pathetic that it has to be us.”