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Digital Health in Acute Care
- 1. mHealth in Acute Care: Where are We Now? Where (Might) We Be Going? Megan L. Ranney MD MPH FACEP Director, Brown EDHI @meganranney / @brownedhi
- 4. Our patients want mHealth: 95% have SMS-capable cellphone 45% have smartphones (rapidly growing) 67% use social media (rapidly growing) 90% interested in tech-based platform to improve their health Ranney, Choo, et al Annals of EM 2012
- 6. Patients are trying mHealth: http://www.pewinternet.org/Reports/201 2/Mobile-Health/Key-Findings.aspx
- 7. Once enrolled, people use it! - mHealth interventions have been shown to be acceptable and result in high engagement even in the highest risk groups • adolescents • Spanish-speaking diabetics seen in the ED • schizophrenics
- 12. Patient engagement & behavior change
- 17. Where is the evidence? Are they safe and private for my patient? How does it affect our workflow? How do I know they’re good? Do they exist for my OS? Do they exist for my disease? She doesn’t even look at my data!
- 21. 1. Privacy/Confidentiality https://www.privacyrights.org/mobile-medical-apps-privacy- consumer-report.pdf
- 22. prviacy
- 24. But….
- 27. 1. Design well
- 29. Need to use…
- 33. Emerging evidence in our field…
- 34. Emerging evidence in our field…
- 36. 3. Optimize the ethics
- 37. Privacy Security Trust Autonomy Justice
- 39. 4. Make it matter in “real life”
- 44. “Brown’s Emergency Digital Health Innovation (EDHI) program exists to facilitate the creation and deployment of effective, evidence based digital health tools in the acute care setting.” www.brownedhi.org @brownedhi
- 48. Bibliography • Sheck, A. (2014) Special Report: Putting an End to Super Users Slipping Through the Cracks. Emergency Medicine News, 36(1), 12-13. • Stokes-Buzzelli, S., Peltzer-Jones, J., Martin, G., Ford, M., Weise, A. (2010) Use of Health Information Technology to Manage Frequently Presenting Emergency Department Patients. Western Journal of Emergency Medicine, XI(4), 348-53. • Stranges E, Uscher-Pines L, Stocks C. Emergency Department Visits and Hospital Inpatient Stays for Bicycle-Related Injuries, 2009: Statistical Brief #135. 2012 Jun. In: Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]. Rockville (MD): Agency for Health Care Policy and Research (US); 2006 Feb-. Available from: http://www.ncbi.nlm.nih.gov/books/NBK99792/ • Unger, L. (2013) Program offers aid to ER ‘super-utilizers’ to cut costs. Courier Journal. April 15, 2013. http://www.courier-journal. com/article/20130413/PRIME01/304140036/Hospitals-target-emergency-room- super-utilizers-cut-down-costs?nclick • U.S. Department of Health and Human Services, Health Information Technology and Quality Improvement. What is mHealth? • Ranney ML, Choo EK, Wang Y, Baum A, Clark MA, Mello MJ. Emergency department patients' preferences for technology-based behavioral interventions. Ann Emerg Med. 2012;60:218-27 e48. • Fox S, Duggan M. Mobile Health. Pew Internet and American Life Project. Washington, DC: Pew Research Center; 2012. • Kumar S, Nilsen WJ, Abernethy A, Atienza AA, Patrick K, Pavel M, et al. Mobile health technology evaluation: The mHealth Evidence Workshop. Am J Prev Med. 2013;45:228-36.
- 49. • Arora S, Peters AL, Burner E, Lam CN, Menchine M. Trial to Examine Text Message-Based mHealth in Emergency Department Patients With Diabetes (TExT-MED): A Randomized Controlled Trial. Ann Emerg Med. 2013. • Head KJ, Noar SM, Iannarino NT, Grant Harrington N. Efficacy of text messaging-based interventions for health promotion: A meta-analysis. Social Science & Medicine. 2013;97:41-8. • Patient Apps for Improved Healthcare: From Novelty to Mainstream. Parsippany, NJ: IMS Institute for Healthcare Informatics; 2013. • Heron KE, Smyth JM. Ecological momentary interventions: Incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol. 2010;15:1-39. • Georgiou A, Prgomet M, Paoloni R, Creswick N, Hordern A, Walter S, et al. The Effect of Computerized Provider Order Entry Systems on Clinical Care and Work Processes in Emergency Departments: A Systematic Review of the Quantitative Literature. Ann Emerg Med. 2013. • Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Beynon M, et al. Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial. Age Ageing. 2013;42:501-8.
Notas do Editor
- So why mobile health? First, it is possible: according to a survey that I completed at my institution in 2011,… 90% are interested in a tech-based platform to improve their health. Rapid growth is seen in ownership of tablets, smartphones, and social media use as well.
- Second, they WANT digital health tools.
- Finally, the are LOOKING for them. According to Susannah Fox’s data, of adult American cellphone users: About 1/3 look up health-related info on their phone About 1/10 have downloaded an app or use texting programs for help. So whether we want it or not, we have to figure out how to use it
- Importantly, this is also one of the few areas with increased funding to innovate.
- And of course – very importantly – we need it. I don’t need to go over all the challenges facing the acute care environment. But you all know that we serve as the entry point for the health care system, right? The vast majority of unplanned admissions come through us. We see a higher-than-average percent of “high risk” patients. Although we are only responsible for ~5% of costs, we determine the course of care. And, of course, we are being held to increasingly rigorous standards around quality, bouncebacks, and length of stay. We are in NEED Of something to help us. Behavioral health… Recidivism… Costs… Entry point for healthcare system… Time pressures…
- OK, so what currently exists? How can it help us? Well, existing mobile heatlh tools get divided into a few “boxes.” The 1st is monitoring & surveillance, either on a patient level or on a population level. This can be things like tracking the frequency of tweets about certain conditions; or can involve tracking patients’ vital signs, and reporting this to doctors; or can involve in-the-moment monitoring, such as the AliveCor device. This is also stuff like what Anand Shah, one of our former residents, is doing with “big data” – using patients’ own data to predict who will do poorly, and then targeting resources to them.
- The 2nd big category is actual delivery of care. This ranges from the program on the left – from Mayo Clinic – to helping patients to triage themselves, to actual online care delivery.
- 3rd is the idea of using digital health to improve patient care through patient engagement. As many of you know, this is the realm in which I spend most of my time – working on apps and text-messaging programs to improve pts’ own coping skills and awareness of their own health conditions. This is an area with a fair amount of evidence….
- In theory, something like THIS will be possible for the future:
- What are some concerns that you have?
- But when I talk about the possibilities with my colleagues and patients, I hear some recurrent themes in their questions. We don’t have answers for all of these questions.
- Lack of applicability to patients’ needs.
- Privacy concerns….. For instance, 72% of popular medical apps presented medium-to-high risk with regard to personal privacy (lower risk if paid app vs free) Disclosure to 3rd parties without consent No ability to opt out Tracking info that you haven’t consented for
- Okay, what’s another way to look at this?
- Do we want to be a dinosaur, or the leaders? Do we want to be NYT, or HuffPo?
- Free/low-cost: > 16,000 patient-facing health-related apps in both iTunes and Google Play stores < 30% of apps downloaded more than 50 times < 10% used more than once Out of ~20,000 consumer-facing health apps, less than 20% of them have ever been downloaded. Just five apps account for 15 person of all health app downloads The minority of apps out there are based on “evidence.” Even fewer are used more than once! ONLY 20% CAPTURE USER-ENTERED DATA
- Other papers: Suffoletto re: alcohol, antibiotic adherence, TBI
- Other papers: Suffoletto re: alcohol, antibiotic adherence, TBI
- What do I do with all this data? If it’s linked to my EHR, how does it stay compliant with HIPAA?
- For each of these case studies, I want you to consider these major areas of ethical quandary, and to come up with solutions that will make you as PROVIDERS feel that it’s ethically ok.
- In theory, something like THIS will be possible for the future: