From text reminders to virtual clinic visits, mobile health (a.k.a. mHealth) is beginning to change the way health care is delivered and received. By improving efficiency and providing convenient access, mHealth has the potential to fulfill the promises of health reform: lower costs, improved outcomes, and higher patient satisfaction.
To be sure, mHealth—or the use of smartphones, patient monitoring equipment, gaming, and other mobile technologies to support medical care and public health—has a long way to go. Medication management offers one example. According to a survey among health plan members from 478 U.S. employers, just 12 percent used texting and 11 percent used mobile apps to manage their medication adherence (Pharmacy Benefit Management Institute, 2013-2014 Prescription Drug Benefit Cost and Plan Design Report, 2013).
Projecting into the future, however, mHealth stands to fundamentally change the traditional patient-provider relationship by enabling clinicians to provide more targeted care and empowering patients to become much more engaged in their care, as the case studies in this feature illustrate:
“Mobile health is truly a game changer in healthcare delivery,” says Joseph C. Kvedar, MD, founder and director of the Center for Connected Health at Boston-based Partners HealthCare, which develops technology-enabled solutions for improving the delivery of health care. “We’re constantly looking at our smartphones, about 150 times a day by some estimates. Because the device is always connected and always on, it can be used for timely, relevant message delivery.”
As providers turn to population health management as a way to improve quality and reduce costs, they are looking for efficient ways to educate community members on ways to maintain healthy lifestyles.
Trying different texting approaches. Boston’s Center for Connected Health recently used texting in a study designed to encourage community members to use sunscreen. All participants were provided with a tube of sunscreen fitted with a device that measured when the tube was opened. About half were sent daily text reminders to wear sunscreen. In the end, 60 percent of participants sent texts were adhering to sunscreen recommendations, versus 10 percent of the control group, Kvedar says.
In another texting study, pregnant women were sent targeted health information based on the baby’s due date. The Center for Connected Health created an algorithm that links the stage of pregnancy and other medical information to timely and relevant health reminders. “We put that information into a database that drives out text messages,” Kvedar says. “Things like: ‘Remember to count your baby’s kicks.’ Or ‘Have you scheduled your ultrasound?’”
A third texting study focused on smoking cessation. For the first time, the texting was two-way. For example, a smoker could text “crave” to a short code and receive automated counseling about how to deal with the craving.
More recently, a new Text to Move campaign was designed to improve the activity levels of 130 Partners Healthcare patients with Type 2 diabetes. Four types of data go into an algorithm that helps determine what messages patients get sent twice a day:
“The messages are contextual, based on what the algorithm knows about each of the patients, helping coach them to be more active,” Kvedar says. For instance, using the information, the system may text a message noting that the patient is usually active when the weather is good, while also noting that rain is in the forecast for tomorrow. Then, the technology will suggest three activities to do indoors the next day to increase activity level.
“That kind of stuff raises eyebrows. Patients find it very endearing,” Kvedar says.
Patients tend to bond with the technology, he says. “People become fond of these messaging systems. That’s not an overt goal, but the more you are engaged in any way, the better your outcomes.”
Ensuring relevant messages. Interim data suggest that the diabetes texting intervention was effective in significantly lowering hemoglobin A1C, compared to a control group.
Kvedar says the messages have been effective because they offer information that is relevant to a person’s life, not just a lecture about healthy habits. The smoking cessation and obstetrical texting programs are currently under consideration to be implemented across the health system, while the diabetes program is being converted into an app, which will initially be available to Partners HealthCare patients. “The app environment is much more flexible, you can do much more with it,” he says. Apps are software applications that are easily downloadable to mobile devices.
Indeed, the number of health-related apps available today is considerable. According to a recent report, there were more than 100,000 mHealth apps published on Apple and Android platforms in the first quarter of 2014 (research2guidance, mHealth App Developer Economics 2014, May 2014).
Apple, Inc., recently energized the health app market with the introduction of a smartwatch that is equipped with a sensor that can track the wearer’s heart rate, an accelerometer to measure total body movement, and other personal tracking abilities. Apple’s new software, which is built into the device, has the potential to share data that is collected via the watch with providers. A lot of questions remain about how exactly the Apple approach will work. Healthcare organizations, including Stanford University Hospital and Duke University, are piloting the software, according to various news reports.
Expanding an app experiment. But it is not just technology giants that are developing apps. Physicians—such as pediatric endocrinologist Jennifer Shine Dyer, MD—are on the frontlines of understanding not only what patients need, but how to give it to them.
Dyer was having trouble getting her teenage diabetes patients to manage their conditions. So she decided to take advantage of their attachments to their phones and other devices by using mhealth approaches to remind the teens to check their blood sugar levels.
“There’s actually something magical about the mobile phone,” says Dyer, who works in private practice in Columbus, Ohio. “Many people have a more personal connection to their mobile phones than their laptops or desktop computers. It’s a tool that really has a lot of power to influence.”
Dyer first conducted a small pilot study to assess the feasibility of a personalized texting program using three subjects from her outpatient clinics who were not taking their insulin. Dyer first engaged these patients with questions about their lives, and only then began asking about their blood sugars. Dyer customized those initial questions to each patient’s interests, asking for example: How is your lacrosse team doing? Or how did you do on your finals? She would then follow up with questions specific to diabetes adherence, such as: What are your glucose levels? How often are your glucose levels high and how often are they low?
Although the text messages were initially effective in getting Dyer’s small group of three patients in the test pilot to better monitor their blood sugars, the effects of texting eventually wore off because patients needed more than weekly conversations to stimulate behavior; they also need incentives, she says. “Adopting healthy behaviors just for the sake of being healthy isn’t something that computes in a younger mind.”
Going public. Working with a software company, Dyer developed a mobile app (EndoGoddess) that automates the text messaging process and, even better, rewards patients who monitor their blood sugars with free music downloads. This was initially sponsored by advertising and funding received to develop the app from not-for-profit and for-profit healthcare IT competitions.
Dyer says the rewards approach worked much better at keeping patients engaged. All patients experienced improvements in insulin adherence and a drop in hemoglobin A1C by a minimum of 1.2 percent and a maximum of 2.5 percent over a three-month period. In addition, Dyer says that small increases in body mass index noted over the three months offer indirect support of a higher amount of insulin dosing, as increases in insulin dosing are commonly associated with weight gain.
After the funds used to support the music downloads were depleted, Dyer developed a second app, called EndoGoal, in an attempt to appeal to diabetic patients outside of her practice. EndoGoal uses a virtual pet dog as a motivator. Users who check their blood sugars receive snacks to feed their virtual dogs. If users do not check their blood sugars, the dog cries.
Currently, approximately 50 to 60 patients in her practice are using the EndoGoal app every day. The app has been downloaded 1,000 times so far, and about half actually use the app. “The dog helps stimulate daily interaction with the app,” she says.
Dyer is securing funding to add a cash option to EndoGoal, which will allow family and friends to reward children and teens for checking their blood sugars with cash via a pre-paid bank card. Dyer believes usage will grow once the monetary rewards function is activated.
Managing complicated chronic conditions outside the hospital setting can be a challenging task for both patients and their caregivers. Routine physician checkups can be burdensome for patients who live long distances from medical offices. Using telehealth programs may help these patients seek care more conveniently.
Visiting via tablets. For the past 15 years, the University of Kansas Medical Center School of Nursing and its Center for Telemedicine and TeleHealth has been conducting research to determine how to provide more convenient care for these types of patients. Since 2012, the medical center has been involved in a study supported by the National Institute for Biomedical Imaging and Bioengineering (grant number R01 EB015911) that involves the use of mHealth technologies in the home setting. The study includes patients with extensive bowel disorders, such as Crohn’s disease and colitis, who typically require daily intravenous (IV) infusion of nutrients and frequent interactions with the healthcare system, says the study’s lead researcher Carol Smith, PhD, RN, a professor at the KU School of Nursing and at the School of Preventive Medicine & Public Health.
Clinicians conduct virtual visits with 45 patients who have been supplied with video- and audio-enabled personal tablets and 4G data plans that allow large amounts of data to be transmitted quickly. The hour-long visits consist of a review of medical history and nutritional status, home care education, and a visual examination of the patient’s IV insertion site and abdomen. “We can see the surgical scars. We see the open wounds,” Smith says.
Previous studies have shown that telehealth consults have reduced infection and depression rates, and increased quality of life for patients.
“We’re also testing to see if this can substitute for the patients’ quarterly face-to-face appointments,” Smith says. At this time, there is no interweaving of face-to-face and virtual physician visits. “We are only testing to see if the PC tablet assessment of the patient can obtain an overall ‘picture’ of the patient’s clinical status,” she says.
The next stage will involve a side-by-side study, which is currently being undertaken by having patients come into a clinic room set up with a tablet. Clinical professionals examine the patients using the tablet and then go into the clinic room to conduct the same exam in person, or vice versa. Results of the two exams are then compared. The tablet-based virtual visit is also filmed; that recording is then evaluated by several clinical professionals.
Improving access. The mHealth approach can enable quicker diagnosis and treatment than if a patient were to set up an appointment for an in-office visit. Because virtual visits can be conducted from home at the time of new symptom discovery, they can be done much sooner than fitting a visit into a clinic schedule, Smith says. Patients forward photographs of their surgical and IV insertion sites, enabling clinicians to review for signs of infection and direct the appropriate treatment, she says.
Patients also transmit virtual urine samples. “We have them take pictures of the urine container with their tablet, and then we can see the amount and the color of the urine, which helps us assess fluid balance and dehydration,” she says.
Because the study is ongoing, the effect of the virtual visits on incidences of infection, depression, and fatigue are still being measured. However, the study has shown that patients—who range in age from children to older adults—have easily adapted to the technology. Each patient received a link to a short video showing how to use the tablet along with graphic illustrations that were printed out for them, Smith says. Only a few of the 45 patients needed help from a technician to set up the technology, Smith says. “Everybody has been able to connect and use the technology without trouble,” Smith says.
Another important benefit of virtual visits is coordinated care. “You can bring the whole healthcare team together in the room for the virtual visit. Not just the physician, but also the social workers, the mental health specialist, and the dietician/nutrition specialist,” she says. “Being able to get all the professionals to see the patient at one time, so everybody is agreeing on the same plan and the patient is heard by everybody, makes a tremendous difference.”
Family members who are involved in the patient’s daily IV care at home are also often part of the virtual visit so everyone involved in the patient’s care can discuss the same plan of care, and hear the same instructions and responses to patient questions, Smith says.
Smith says the study will continue through 2015 and will involve another phase that includes an additional set of patients and their family members. Also, the improved social support from the virtual interactions of these families will be evaluated.
For more on telehealth, see the case study about the Maryland eCare approach. Six rural hospitals have developed a collaborative model for delivering intensive care services using telemedicine technology.
As with the virtual visits, the benefits of mobile technology are often found outside the hospital setting. However, some providers are leveraging mobility to improve the patient experience during hospital stays.
One such app, developed internally at Boston Children’s Hospital (BCH), helps patients and their families navigate the hospital journey, says Naomi Fried, PhD, chief innovation officer for BCH. During a test pilot of the app, called MyPassport, 30 patients were given a personal tablet to access the app, which enables them to:
Overall, the app has enhanced provider-patient communication and provided patients with a self-service mechanism they can access at their convenience, Fried says. “Patients really like this solution,” Fried says. “They really feel much more empowered.”
BCH plans to expand the program throughout the hospital as well as license it to other hospitals. Once that happens, patients will not be given tablets, but will access the apps using their own mobile devices, Fried says.
Although efficiency may be enhanced, the app is primarily a way to improve patient experience. “We know we deliver outstanding clinical care. But what can we do about some of the more intangible aspects of care such as patient confusion? How can we empower our patients and their families? They want to have access to their information. They want to know their lab results and their care plan. This type of solution really helps us give patients what they’re looking for.”
For a healthcare industry that is going through enormous change, mHealth has the potential to offer solutions that can help providers and patients exchange health-related information and provide for a smoother experience in delivering care. That is not to say that mHealth is not without its downsides.
Lack of integration. One negative is that the majority of mHealth apps are too consumer-oriented, says pediatric endocrinologist Dyer. “So it’s all based on the consumers themselves managing their health. And there’s not really a lot of integration into the medical system.”
Dyer, who treats diabetes patients, sees more benefits in the technology once various instruments (such as glucometers, insulin pumps, and other medical devices) can be run on the same operating platform. Such devices often cannot communicate because proprietary restrictions will not permit it, which makes managing the data from these various systems challenging.
“Integration of information from devices and the medical record is really what’s needed to go beyond the consumer space. And that is really hard. That’s what I see being a roadblock to really making the biggest impact in health care,” Dyer says.
Payment questions. Reimbursement is another challenge. Some in health care are calling for better reimbursement rules that will further the use of telehealth tools and programs. This past June, the American Medical Association (AMA) approved a list of guiding principles “for ensuring the appropriate coverage of and payment for telemedicine services,” which includes use of mobile technology.
Part of the policy on payment, for example, calls for the Centers for Medicare & Medicaid Services (CMS) “…and other payers to separately recognize and adequately pay for non face-to-face electronic visits.” In July, CMS released a proposal for expanding telehealth coverage to include such areas as wellness and behavioral health.
Currently, CMS along with a few payers, including WellPoint, Aetna, and Highmark, cover some telemedicine service, according to the AMA. However payment for telehealth services varies widely. The AMA contends that this variation has created barriers to the further adoption of telehealth programs.
WellPoint recently began offering online clinical visits for health plan members in 11 of the 14 states in which it operates. In the remaining three states, medications cannot be prescribed online so the online visit is not offered, says WellPoint communications director Lori McLaughlin. The visit allows immediate access to physicians via two-way audio/video through a desktop computer or mobile device.
WellPoint’s online clinical visit is also available to general consumers in 45 states for $49 per visit. Some states require a face-to-face relationship with a physician before telehealth visits can be offered, McLaughlin says.
Although state regulations can act as a barrier to online care, such challenges may recede as virtual services for non-emergency visits become valuable alternatives to more expensive urgent care and emergency department visits, McLaughlin says. “Given the dynamic regulatory environment, the expected primary care doctor shortage, and the number of estimated consumers who will be seeking more accessible care, we anticipate that regulations will continue to evolve favorably,” she says.
Although it may be too early for concrete results on cost savings and quality improvements, mHealth is proving to be a sure winner in patient satisfaction—and that can definitely have bottom-line results for healthcare providers. “In general, these texting programs make provider-patient communication more efficient,” says the Center for Connected Health’s Kvedar.
As reimbursement models shift to reward outcomes rather than services, these programs may also reduce costs. “We believe and have indirect evidence that texting does cut down on office visits. We don’t have hard data on that yet,” says Kvedar. “We believe that, properly implemented, these programs will lower unnecessary office visits and improve the quality of communication in necessary office visits.”
The prospects for mHealth, likewise, are very encouraging as health care becomes even more fast-paced, complicated, and data-driven. “Mobile solutions really help us address these challenges and more,” Fried says. “There’s a lot of opportunity right now to create solutions that will drive clinical efficiency, save time, facilitate better clinician-patient communication and, ultimately, save money and improve outcomes. We believe there’s a growing realization that these tools really can benefit and enhance how we deliver care.”
Karen Wagner is a freelance healthcare writer in Forest Lake, Ill., and a frequent contributor to HFMA publications.
Quoted in this article:Jennifer Shine Dyer, MD, is a pediatric endocrinologist, Central Ohio Pediatric Endocrinology and Diabetes Services, Columbus, Ohio.Naomi Fried, PhD, is chief innovation officer, Boston Children’s Hospital, Boston (Twitter @NaomiFried).Joseph C. Kvedar, MD, is founder and director, Center for Connected Health, Partners HealthCare, Boston.Lori McLaughlin is communications director, WellPoint, Indianapolis, Ind.Carol Smith, PhD, RN, is a professor, University of Kansas Medical Center School of Nursing and at the School of Preventive Medicine & Public Health, Kansas City, Kan.
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