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Emerging Technologies for Patient
Engagement and Mobile Health
DoD & VA EHR Symposium
Kenyon Crowley MBA MS CPHIMS
October 1, 2013
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
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
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
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
Potential impacts
10/01/20136
Source: Veroff D. et al. (2013) Health Affairs
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
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
10/01/20139
A framework for patient engagement
10/01/201310
Source: Carmen K. et al. (2013) Health Affairs
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
Continuum of mHealth Tools
Source: Nilsen W (2012) NIH12 10/01/2013
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
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
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
PTSD Coach used in VA & DoD
 Self-Assessment
 Manage Symptoms
 Find Support
 Learn about PTSD
10/01/201316
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
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
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
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
10/01/201321
10/01/201322
10/01/201323
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
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
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
Games for Health
10/01/201327
Definition: application of game psychology to health tasks
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
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
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
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
2 graphs
10/01/201332
Segmenting market players
Zombies, Run!
 Top paid health and fitness apps #4
 Key = Fun
33 10/01/2013
Mango app
 Health education and adherence with rewards including social
conscience type rewards
34 10/01/2013
mHealth Products versus Platforms
10/01/201335
Aetna CarePass API’s (subset)
36 10/01/2013
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 http://bluebuttonplus.org/index.html
Open mHealth
38
PTSD management
Type II diabetes
Health 2.0
39
Data Source
 Rare disease
community
 Amyotrophic Lateral
Sclerosis (ALS)
 Data collected using
web crawler
 Patient profiles
 Threads and replies in
forum (reflects
participation)
40
Threads vs Replies
Thread
Reply
41
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
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
10/01/201344 Source: http://www.wired.com/magazine/2010/11/ff_bloodwork/all/
Available online at:
http://ter.ps/designguide
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
It takes an ecosystem…
47
Innovation
and Value
Customers
Employees
Scientific
Community
Partners
Other
Stakeholders
Thank You!
 Kenyon Crowley
 kcrowley@rhsmith.umd.edu
 @healthIT
 Website: http://ter.ps/chids
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

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Emerging Technologies for Patient Engagement and Mobile Health

  • 1. Emerging Technologies for Patient Engagement and Mobile Health DoD & VA EHR Symposium Kenyon Crowley MBA MS CPHIMS October 1, 2013
  • 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. 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. 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. 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. Potential impacts 10/01/20136 Source: Veroff D. et al. (2013) Health Affairs
  • 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. 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
  • 10. A framework for patient engagement 10/01/201310 Source: Carmen K. et al. (2013) Health Affairs
  • 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. Continuum of mHealth Tools Source: Nilsen W (2012) NIH12 10/01/2013
  • 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. 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. 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. PTSD Coach used in VA & DoD  Self-Assessment  Manage Symptoms  Find Support  Learn about PTSD 10/01/201316
  • 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. 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. 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. 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
  • 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. 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. 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. Games for Health 10/01/201327 Definition: application of game psychology to health tasks
  • 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. 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. 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. 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
  • 33. Zombies, Run!  Top paid health and fitness apps #4  Key = Fun 33 10/01/2013
  • 34. Mango app  Health education and adherence with rewards including social conscience type rewards 34 10/01/2013
  • 35. mHealth Products versus Platforms 10/01/201335
  • 36. Aetna CarePass API’s (subset) 36 10/01/2013
  • 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 http://bluebuttonplus.org/index.html
  • 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
  • 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. 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
  • 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. It takes an ecosystem… 47 Innovation and Value Customers Employees Scientific Community Partners Other Stakeholders
  • 48. Thank You!  Kenyon Crowley  kcrowley@rhsmith.umd.edu  @healthIT  Website: http://ter.ps/chids 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