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Utilizing three important screens to improve health: the computer, cell phone
and televisionJames 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
1. Improve health and reduce the digital divide through technology development, adoption and utilization
2. Empower patients through innovative use of technology
3. 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 FractureAtrial Fibrillation
Community Acquired PneumoniaUrinary Tract Infection
DiabetesColorectal Cancer
Congestive Heart FailureHypertension
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
Do
Know
Real world
Incentives for the process
Hypothetical growth with knowledge and resources
Pay for results
Empower Consumers
Sources used to find information
The future is already here, it's just not evenly distributed
William GibsonThe Economist 2003
Information Systems
Financial InformationDemographics
Notes, ImmunizationsLabs, Medications
ImagesConsults, Reports
Important Documents
Financial InformationDemographics
Diagnosis, ImmunizationsLabs, Medications
ImagesConsults, Reports
Important Documents
EMRs populated withdata from “reliable” sources
PHRs populated withdata from patient sources
Systems owned Patient owned
Definition--Personal Health Record
A longitudinal record of individual healthThe 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 patientThe 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
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
Investigators: Joan HiltonUrmimala SarkarDean SchillingerDavid ThomRicardo MunozNeda Ratanawongsa
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”1) Make a capital letter; 2) Use numbers and letters;3) Locate a cursor; 4) Copy something; 5) Paste something; 6) Scroll down or around on the
page;7) Make the @ sign; 8) Enter something; 9) 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 FunctionsReminders to patients
ImmunizationsAppointmentsPap smearsMammogramsMedication Adherence
Notifications for patientsLab results are available for viewingClinician follow-up is expectedMedication Refills should be requestedTargeted behavioral interventions for: Depression
intervention, Tobacco Abatement, Anxiety control
Study Design
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
Investigators: Joan Hilton, Monica GandhiTeam members: Tracy NunneryLindsay Halperin, Kelly Bryant
Automating SMS --closing the loop
It is complex…
Total Screened = 476
Enrolled = 99 patients (20.8%)
Types of Phones33 Smartphone
8 iphone4 blackberry21 other full keyboard,web enabled phones
62 Standard Phone
Phone Providers 48 Metro PCS (48%)14 AT&T 12 T Mobile6 Sprint 8 Verizon Wireless 4 Virgin Mobile2 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 reminders20% opted for messages 3 times a week10% opted for messages once a week
New model of workManaging 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 assistancePatients 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 thisa 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?1.Make or change a visit?2.Refill meds or list my meds?3.Check labs?4.Receive advice now?5.Get a call back?
3. Check Labs
What labs?1.T-cells2.HIV Viral load3.Liver studies4.Cholesterol studies5.Diabetes labs
1. T-cells
Your last 3 T-cells were:
520 on September 24, 2010310 on March 15, 2010421 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 expensesEncourage connection to the health systemInvolve 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
04/12/23Supported by AHRQ HS017784; NIH: RR024369 and MH088341
NIDA R01DA032057 54
Jackie SoKelly BryantLindsey HalperinSkip LeasureMitch RobertsTracy NunneryOlivia ChangRaeni MillerRobert ThawleyJoan HiltonMonica GandhiAdam CarricoLeslie 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 Kahn415-699-1118
[email protected]://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.”
