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2 stanford talkdyer

  1. 1. Jennifer Shine Dyer M.D., M.P.H . Chief Medical Advisor eProximiti 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.
  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] © 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:
  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 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>,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>,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>,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>,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:
  59. 67. <ul><li>1983: Inventor Martin Cooper is credited with developing the first cell phone approved for commercial use. </li></ul>,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:
  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>,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://
  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>,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>,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>
  70. 78.,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.