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Emerging Technologies for Patient Engagement and Mobile Health


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Emerging Technologies for Patient Engagement and Mobile Health, presented at the DoD & VA EHR Symposium, October 1, 2013

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Emerging Technologies for Patient Engagement and Mobile Health

  1. 1. Emerging Technologies for Patient Engagement and Mobile Health DoD & VA EHR Symposium Kenyon Crowley MBA MS CPHIMS October 1, 2013
  2. 2. Agenda  Briefly who CHIDS is  Patient engagement and activation  Tools and technologies being deployed in pursuit of activating patients  Importance of design 10/01/20132
  3. 3. Strategy TechnologyPolicy About CHIDS Center for Health Information & Decision Systems Mission  Research, analyze, and recommend solutions to challenges surrounding the introduction and integration of information and decision technologies into the health care system  Improve the practice and delivery of health care by offering researched solutions that impact safety, quality, access, efficiency, and ROI Partner Ecosystem  Federal and state agencies (HHS, NSF, ONC, FDA DOD, State of MD)  Private corporations (Children’s National, J&J, CareFirst BlueCross BlueShield, Cisco, Small and Mid-Size firms)  Not-for-profits (CDT, eHealth Initiative) Resources  Renowned scholars from multiple disciplines  Research fellows, students, partners 3 10/01/2013
  4. 4. Research Focus Areas Impact and Comparative Effectiveness of Health Information Systems New Models of Care (ACO, HIE, PCMH, Care Transitions) Healthcare Analytics (Data- driven Health Services Insights, Modeling, Operations) Consumers, Quality & Transparency, and Social Media 4 10/01/2013
  5. 5. Terminology  “Patient activation” refers to a patient’s knowledge, skills, ability, and willingness to manage his or her own health and care.  “Patient engagement” is a broader concept that combines patient activation with interventions designed to increase activation and promote positive patient behavior, such as obtaining preventive care or exercising regularly.  “Mobile health” is the application of wireless and mobile technologies designed to improve health research, health care services and health outcomes. (Not just apps and phones) 10/01/20135
  6. 6. Potential impacts 10/01/20136 Source: Veroff D. et al. (2013) Health Affairs
  7. 7. Barriers to patient engagement  Patients  Lack of health literacy  Only 12% of patients can fully understand the information given to them to make proper health decisions  Diversity of patients  Cognitive differences among patients  Extreme sensitivity to costs  Poor usability of systems  Laziness – may offend patient advocates but true in many cases – also known as the “why diet when there’s a pill for that syndrome”  Providers  Overworked physicians indicate cannot do more  Pushback from healthcare providers when they are held accountable for their patient’s actions  Insufficient provider training  Inadequate clinical information systems  70% of physicians believe health IT tools will cost more than the benefits received 10/01/20137
  8. 8. Effective Patient Engagement Strategy  Shared decision-making among patients and clinicians  Provide patients with information they are able to understand  Teach patients and families how to manage their conditions  Use easy-access + easy-to-use technology for patients to engage  Have a comprehensive and historical patient record, and effective patient identity management method  Track and share the impact of activities on patient health  Get feedback from patients (surveys, focus groups, complaints)  Get patients involved in an advisory capacity 10/01/20138
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  10. 10. A framework for patient engagement 10/01/201310 Source: Carmen K. et al. (2013) Health Affairs
  11. 11. Patient engagement tool: Mobile Health  85% US adults own mobile phone; 53% own smartphone.  19% of smartphone owners have at least one health app on their phone. Exercise, diet, and weight apps are the most popular types.  One in three cell phone owners (31%) have used their phone to look for health information. (17% one year ago).  According to a March 2013 study, the market for mHealth services has now entered the commercialization phase and will reach $26 billion globally by 2017.  Market forecasted to grow at a CAGR (compound annual growth rate) of 40.4 % through 2015.  According to research by HIMSS Analytics, about half of all doctors use mobile health apps, and a quarter of consumers do. Sources: Pew Mobile Health Survey 2012, Mercom Report 2013, Image – Rock Health 11 10/01/2013
  12. 12. Continuum of mHealth Tools Source: Nilsen W (2012) NIH12 10/01/2013
  13. 13. BioZen developed by DoD  Portable, low-cost way for patients and physicians to receive biofeedback in and out of clinic  Show real-time data from multiple body sensors  Create notes for recording session 10/01/201313
  14. 14. PE (Prolonged Exposure) Coach by DoD and VA  Support the tasks associated with prolonged exposure treatment of PTSD  Aid patients and therapists during clinical care  Streamline the professionally- guided treatment of PTSD  Interactive respiration retraining 10/01/201314
  15. 15. Life Armor for military community  Browse information on 17 topics, including sleep, depression, and post-traumatic stress  Measure and track symptoms by self-assessment  Watch videos relevant to each topic from veterans, military family members and other service members 10/01/201315
  16. 16. PTSD Coach used in VA & DoD  Self-Assessment  Manage Symptoms  Find Support  Learn about PTSD 10/01/201316
  17. 17. Big issues  Limited number of mobile health apps are constructed on design principles that are theoretically derived, and little is known about their effectiveness.  How to sustain use?  Military context – Numerous device security issues 10/01/201317
  18. 18. Patient engagement tool: Secure Messaging  Secure messaging offers patients, their caregivers, and/or advocates the ability to communicate securely and electronically with health care providers.  The secure messaging framework is built around existing communication tools such as the patient portal, secure email, and the PHR.  The correspondence can be initiated by either the patient, caregiver or the provider.  Messaging may contain structured, unstructured or mixed format content.  PHRs often have a secure messaging system with security greater than standard emails. 10/01/201318 Source: HRSA
  19. 19. Air Force PHR / SM Study  Air Force Medical Service implementation of a PHR with secure messaging (SM) in Dec 2010 at Joint Base Richardson-Elmendorf in Alaska  Part I Objective: Determine factors that influence patients’ intentions to use PHR  System capabilities and benefits used:  Request your next appointment  Request medication renewals  Receive your test and lab results  Maintain a Personal Health Record (PHR) to manage your health  Communicate online with your healthcare team about non-urgent symptoms  Avoid unnecessary office visits and telephone calls  Request a copy of your immunization record  Access a large library of patient education materials  Additional features have come online since 2010 10/01/201319
  20. 20. Patient Enrollment Process & System Interaction Elmendorf MTF Registration Desk INTERNET MiCare Portal (PHR/SM) Visit MTF to register (show military ID) Updates to PHR, messages to/from providers Patient registration information Patient’s medical information Messages to/from patients 20 10/01/2013
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  24. 24. Summary of Early Findings  Positive “expectations” among patients, less so for providers  Adoption is trending up but still low  Key is personal promotion and recommendation to patients by providers  Usage is low  Provider-initiated secure messaging  Identification and designation of super users  Compelling “use” stories  Overcoming provider resistance  Realistic messaging and expectation management  Sufficient training of providers/staff  Workflow and business rules 10/01/201324
  25. 25. Air Force PHR / SM Study  Part II Objective: Assess impact of PHR/SM on health services utilization  Primary Care Appointments  Telephone Consults  Emergency Room Visits  Inpatient Stays  Clinical outcomes  Comparing portal users to similar non-users  Analysis in progress 25 10/01/2013
  26. 26. More tools: Era of the Quantified Self and Trackers  7 in 10 US adults keep track of a health indicator  60% of US adults say they track weight, diet, or exercise routine  New ways for easing burden data entry resulting in increased monitoring and support services  Popular in employer wellness initiatives 26 Source: Tracking for Health (2013) Pew Internet 10/01/2013
  27. 27. Games for Health 10/01/201327 Definition: application of game psychology to health tasks
  28. 28. Why Games?  Structure information such that a complex topic is more accessible  Decades of research has provided insights about how people learn and change their health behaviors --- We can integrate this understanding into the design of highly engaging health games  Game play can influence risk perceptions, knowledge, skills, and self-confidence  Foster peer influence  Done well can be fun  Military environment – already sense of teams, competition to leverage 10/01/201328
  29. 29. Health gaming @ CHIDS w/ VA  Mobile Social Engagement For Older Adults Management of Diabetes Type II  Design elements that facilitate older adults’ adoption and use of new technology, particularly for health-related purposes  Examine the stages of behavior change from the initiation of the intervention to behavior maintenance, including the examination of intervening variables  Social and behavioral aspects of disease management  Combing provider influence with peer influence  Use of health coaches 10/01/201329
  30. 30. Social engagement research  Impact of different types of rewards and incentives  Personalization of health message content and frequency  Optimizing team structures  What educational materials improve health literacy  Personality-driven interactions  Data capture ease of input 10/01/201330
  31. 31. VA Mobile Health Family Caregiver Pilot  May 2013, Caregivers began receiving VA-loaned iPads loaded with a Suite of Apps to test over a 12-month period  Care4Caregiver  Health Advocate  Health Assessment  Journal  Notifications and Reminders  Pain Coach  PTSD Coach  RxRefill  Summary of Care 10/01/201331
  32. 32. 2 graphs 10/01/201332 Segmenting market players
  33. 33. Zombies, Run!  Top paid health and fitness apps #4  Key = Fun 33 10/01/2013
  34. 34. Mango app  Health education and adherence with rewards including social conscience type rewards 34 10/01/2013
  35. 35. mHealth Products versus Platforms 10/01/201335
  36. 36. Aetna CarePass API’s (subset) 36 10/01/2013
  37. 37. Blue Button+ API 37 “All patients whose providers use Meaningful Use Stage 2 certified technology have the ability to view, download, and securely transmit their clinical data from their provider’s Electronic Health Record into another product or holding place of their choice” ONC Blue Button Co-Design Challenge Implementation guide at
  38. 38. Open mHealth 38 PTSD management Type II diabetes
  39. 39. Health 2.0 39
  40. 40. Data Source  Rare disease community  Amyotrophic Lateral Sclerosis (ALS)  Data collected using web crawler  Patient profiles  Threads and replies in forum (reflects participation) 40
  41. 41. Threads vs Replies Thread Reply 41
  42. 42. PLM online community ALS 42 Methods and Main Findings • Exponential random graph models • Track direction, content and reaction to information shared in social networks • Net inflow from urban to rural patients participating in an online health community • Disease prognosis, treatment experiences, emotional
  43. 43. Role of Design in Patient Engagement 10/01/201343 “Long dominant in online search, advertising, and maps, Google has shifted gears from utility to beauty” Fast Co. 2013 Consumer‐friendly design can make the difference between incomprehensible and meaningful, between information overload and health data that’s personal, relevant, and actionable. Thomas Goetz TEDMED 2013 “A smart product is built with the human form in mind: Rather than us having to integrate it into our lives, the product instinctively conforms to us.” Margaret Rhodes Many promising inventions flop, not because they aren't useful, but because they aren't appealing. Kenyon 9/30/13: Apple surpasses Coke as most valuable brand
  44. 44. 10/01/201344 Source:
  45. 45. Available online at:
  46. 46. Designing consumer HIT applications  Use methods that include high levels of user involvement and iteration. Iterate and involve users early and often.  Use prototypes and consumer feedback based on their use of the prototype.  Most products use one or more of the following design methods: prototyping; agile development; heuristic evaluation; top-down design; lean product development; and Goals, Operations, Methods, and Selection Rules (GOMS).  Ensure the design team has medium breadth in regard to team size and the skill-sets represented.  Engage human factors experts in the design team.  “Keep it simple” - Choose a parsimonious set of features to include in the application.  Pay careful attention to user characteristics and context of use 46
  47. 47. It takes an ecosystem… 47 Innovation and Value Customers Employees Scientific Community Partners Other Stakeholders
  48. 48. Thank You!  Kenyon Crowley   @healthIT  Website: 48 “if you want to understand a sales person’s behavior, study their commission plan. If you want to understand a doctor’s behavior, understand their reimbursement model.” - Leonard Kish