The mHealth Data Deluge

Victoria L. Tiase, MSN, RN-BC

PhD Student, College of Nursing 

University of Utah

   With the advent of the smartphone, we have more data at our fingertips than ever before.  According to the Pew Research Center, 95% of Americans now own a cellphone of some kind and just over one-in-ten American adults are “smartphone-only” internet users - meaning they own a smartphone, but do not have traditional home broadband service. Android users have access to over 2.8 million apps and it’s estimated that there are over 165,000 health-related smartphone apps available for public use.  Health care apps are used for a variety of reasons such as health promotion, disease management and communication with providers.  However, for as ‘smart’ as we’ve become, there are still many unanswered questions worthy of research:  

        

1) Are users interested in using health apps and if so, how will they be used?  

2) Are providers prepared to receive another source of data?  What are the integration and visualization needs? 

3)  Can mHealth data help us understand more about populations?  What is the role of mHealth data in the co-production of health?

 The Supplier

            

           Health related applications are used for a variety of purposes.  Users are armed with data to make decisions, track vital signs or refill prescriptions from the palm of their hand.  Apple’s HealthKit and Google Fit allow users to bring together health data from multiple apps to be collated and organized for easy view.   The movement towards consumer-directed exchange is encouraging the development of methods to pull data from your medical records from your provider to an app on your phone allowing for sharing to chosen family members or providers.  All allowing users to have a vast amount of health data.

            However, very few apps are evidenced based. Additionally, a method to certify or credential health apps does not exist today.  It is unclear to what extent users understand the associated privacy and security issues with mHealth data; exactly what is being collected on their smartphone and who has access to it.   In addition, little work has been done to examine the health literacy issues; whether they are the same or different when it comes to mHealth data.   With these issues in mind, it is important to research the use aspects of health apps considering the development of new education strategies may be needed.  

The Translator

            Providers are still recovering from the transition from paper to electronic medical records and are left making sense of the sea of data that is constantly produced.  However, mHealth data can be an additional rich source of data that may not be captured during a visit assessment due to lack of time or poor recall. Some mHealth apps can serve as powerful tools to enhance the patient-provider dialogue and support shared decision making and thus add value to the relationship by allowing for communication that extends beyond the visit. But many providers are not prepared to collect and analyze mHealth data.   A recent study by PricewaterhouseCoopers found that the ability for providers to integrate data from mHealth devices is lacking.  Work is needed to understand how to make mHealth data actionable at the point-of-care in accordance with clinical workflows for greatest leverage.

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The Co-Production Future

            According to Dr. David Nash, “85 percent of a population’s well-being, its quality of life, is due to factors other than medical care” which means that only about 15% of healthcare occurs inside the four walls of a hospital or practice setting.  Ubiquitously, mHealth data allows for the collection of data anywhere, anytime.  It has potential to put patients in control of their personalized data and potentially, their health.  This can lead to a shift to the co-production of health by which patients and providers partner together, both experts armed with data, allowing healthcare to become relationship centered.

The deluge of mHealth data provides many opportunities to study ways to encourage behavior change, foster healthy lifestyles and support better management of chronic conditions.  Research is needed in the areas of usability, education and health care outcomes.  Ultimately the use of mHealth apps has the potential to encourage and empower patients, reduce workload on the system and improve health.  Our data research strategies should anticipate this future.

Links to Hyperlinked Text:

Pew Research Center: http://www.pewinternet.org/fact-sheet/mobile/

Apple’s HealthKit: https://www.apple.com/ios/health/

Google Fit: https://fit.google.com

Study: https://www.pwc.com/us/en/health-industries/health-research-institute.html

Dr. David Nash: http://www.jefferson.edu/university/population-health/faculty-staff/faculty/nash.html

Additional Reading:

Batalden, M., Batalden, P., Margolis, P., Seid, M., Armstrong, G., Opipari-Arrigan, L., & Hartung, H. (2015). Coproduction of healthcare service. BMJ Quality Safety, bmjqs-2015.

Lobelo, F., Kelli, H. M., Tejedor, S. C., Pratt, M., McConnell, M. V., Martin, S. S., & Welk, G. J. (2016). The wild wild west: A framework to integrate mhealth software applications and wearables to support physical activity assessment, counseling and interventions for cardiovascular disease risk reduction. Progress in cardiovascular diseases, 58(6), 584-594.

Schnall, R., Rojas, M., Bakken, S., Brown, W., Carballo-Dieguez, A., Carry, M., ... & Travers, J. (2016). A user-centered model for designing consumer mobile health (mHealth) applications (apps). 

Journal of biomedical informatics, 60, 243-251.

Woldeyohannes, H. O., & Ngwenyama, O. K. (2017, July). Factors Influencing Acceptance and Continued Use of mHealth Apps. In International Conference on HCI in Business, Government, and Organizations (pp. 239-256). Springer, Cham.

The New Age(ing) Paradigm: Healthier, Wealthier and Wiser

Francine B. Jensen
PhD Student
College of Nursing
University of Utah

Aging—it is upon you and me as we accrue weeks and months, one day at a time.  The length of time we can expect to live is increasing as well.  According to the US Census Bureau, Americans are living nearly double the years we were a century ago. 

Year	Male life expectancy in years	Female life expectancy in years
1900	46.3	48.3
1950	65.6	71.1
1990	71.8	78.8
2012	76.4	81.2

                                                          Life Expectancy, Centers for Disease Control 

WHY are we living longer?

Living longer can be attributed to many social and medical advancements since the 1900’s, including embracing the germ theory, discovering antibiotics, implementing vaccinations, and improving water treatment and sanitation.  Diseases that maimed or killed our progenitors, like cholera, tuberculosis, polio, measles, and the mumps, are now treatable and avoidable.  Living longer is great news, right?

Living longer, but at what cost?

We are all aging at different speeds and with different results.  Just look around you---you have seen 90-year-olds who look like they’re 70, and 65 year olds who look like they’re 80.  These differences can be attributed to a web of factors: genetics, environmental influences, exposure to toxins, dietary nourishment, occupation, stress, and co-morbidities, to name a few.  Some of these factors we can change, others we can’t. Unfortunately for some people, living longer means being sicker with chronic and multi-morbid conditions.   

Baby Boomers:  Wealthier and Wiser 

Boomers, the largest cohort entering old age currently, are predicted to live longer than previous generations.  More Boomers live in non-traditional home environments, have spent more time in the workforce due to the economic downturn of 2007, have more savings, use more electronic technology and are savvy with cell phones, tablets and computers (Sugar, 2014).  They were of age in the Vietnam War and watched women’s and civil rights unfold.  Due to their life experiences, Boomers are redefining what aging means and are challenging us to think about aging in different ways.  

And the U.S. government and scientists are responding, working on ways we can age better and look forward to healthier futures with the years we have left.  

Paradigm Shift 1: Healthier Aging Now and in the Future

The government and providers are serious about stimulating the public health conversation.  A paradigm shift in the last twenty years has turned America from a disease-treating nation to a health-promoting, disease-avoiding nation with the advent of the government’s initiative Healthy People 2000, 2010, and 2020.  The Affordable Care Act emphasizes access to care for everyone, making sure that as we age, we receive medical support across the lifespan.  In addition, national governmental research entities, like the National Institute on Aging, are allocating research dollars towards understanding diseases of aging, like Alzheimer’s disease.

With changes to affordability and accessibility, the aging landscape is changing for the better.  A paradigm shift means thinking about aging in new ways.  Researchers are primed to try new approaches.  

What the future looks like:  Expect to see more research results guiding aging strategies.

 Paradigm Shift 2:  Precision Medicine and Aging

Think genetic and specific: precision medicine is medical strategies for the individual person.  Precision medicine avoids a one-size-fits-all approach to aging, taking in to account your genetic make-up and the specifics of your aging process.  In 2016, President Obama announced the paradigm shift toward precision medicine with the Precision Medicine Initiative, pledging research dollars to accelerate progress toward precision treatments.  We are all uniquely aging, and precision medicine will help us age better by:

·         Screening for your genetic disease risk—catch it before treatment is needed

·         Treatment plans specific to your body’s genetic code

·         Medications dosed at your therapeutic level—treat to your threshold of appropriate responses

·         Targeting tumors and killing them quickly and efficiently—treat precisely what needs targeting

An invitation has been extended to participate in precision medicine research offered through the All of Us initiative, sponsored by the National Institutes of Health.  The goal is to have one million participants’ data gathered “to accelerate research and improve health.” This will go a long way toward helping us understand issues associated with aging.

Paradigm Shift 3:  Team Science and Aging

We are better together.  In the past, researchers worked in isolation to solve problems.  However, the new approach in research is using Team Science. Team science is a paradigm shift that harnesses the collaborative powers of researchers across disciplines to tackle sticky, complex, multi-factorial problems.  The increasing internet abilities harnessing Big Data has enabled this shift to occur.  Working on ubiquitous problems common to humankind just got easier. The realities of this are that researchers can connect with like-minded researchers around the world, and the power of their studies to benefit us has increased.

The aging-well paradigm lends itself to a team-science approach, as stakeholders collectively put their minds toward helping people feel, act and live better.  Innovative research strategies, like Patient Centered Research approaches, listen to aging people’s concerns and suggestions while designing research projects.  As older adults become more involved in research, outcomes will be strengthened and benefit older adults throughout the world.

What the future looks like:  Researchers, aging adults, doctors, nurses, physical therapists, economists, psychologists, sociologists, insurance companies, healthcare systems and others, combining efforts to design research strategies to improve aging’s future landscape.  What can you do?  Get involved in aging research in your area.

Health Technologies: Various Kinds and Purposes

In the last decade, the technological explosion has populated our world with devices and apps.  Technologies provide real-time information about what we do and when we do it.  For those aging, electronics are powerful tools that can:

• ·         Remind us when and what to eat
•        Monitor our movements
•        Encourage us to exercise
•        Track our intake and output
•        Notify of a fall or life threatening cardiac rhythm

Remember the Boomers?  Many have money to spend on devices that perform these functions, thereby assisting them to age better.  Younger generations are already primed to develop and use technological advances to assist them aging better than their parents and grandparents.

Challenges to consider: How do we help aging adults tap into the power of gadgets, apps, and electronic health information to promote their health?

Another exciting development with advancing technology is the field of regenerative medicine.  Previously when bodily function was lost due to aging or disease, there was no recourse.  However recently, 3-D bio printing is allowing us to manipulate materials in order to bio-print tissues and structures for the human body (Murphy & Atala, 2014).

Image of schematic of bioprinting.  License: Centromere121 (https://commons.wikimedia.org/wiki/File:Organ_printing_Step_1-2-3.png), Organ printing Step 1-2-3, https://creativecommons.org/licenses/by-sa/3.0/legalcode

Bladders, cartilage, and skin have been successfully printed, and the capabilities are growing exponentially.  For the aging adult, bio-printing offers new vistas for degenerating body parts thereby prolonging functionality.  The future is brighter for some diseases as this capability grows.  

The type of tool that does the work to bioprint. Image of Bioprinter obtained from By Андрей Ильин [CC0 or CC0], via Wikimedia Commons; Attribution not legally required.

What Can You Do?

Aging is a complex process.  While researchers are helping delineate many aspects of aging, there are things we can do to help ourselves.  Reichstadt et al. (2010) identified ways we can psychologically age better, including staying involved in a range of activities to engage in life, purse novel activities, connect with family and friends, and generate social interactions.  Gerontologist Judith Sugar (2014) notes additional strategies to stay physically heathy while aging:

• Consistently exercise with non-weight bearing and weight bearing activities
•  Eat a variety of foods
•  See your doctor for routine care and worrisome symptoms
•  Decrease your levels of stress
•  Sleep well

Start Early, Be Involved

What does this mean to you and me?  None of us is getting any younger, yet there is so much we can do to age better than we are.           

• Actively buy in to the aging-well paradigm. 
• Take advantage of precision medical strategies that are increasing exponentially.  
• Let technology assist you with devices and prompts to eat well, move more, and stay informed.
• Get involved in the aging research.

By utilizing these strategies, we surely can age healthier, wealthier and wiser than we currently are.

References

US Census Bureau  https://www.census.gov/prod/99pubs/99statab/sec31.pdf

Centers for Disease Control  https://www.cdc.gov/nchs/data/nvsr/nvsr65/nvsr65_08.pdf

National Institute on Aging https://www.nia.nih.gov/research/publication/global-health-and-aging/living-longer

Sugar, J. (2014).  Introduction to aging: A positive, interdisciplinary approach. New York, NY: Spring Publishing.

Healthy People 2020 https://www.healthypeople.gov/

Affordable Care Act https://www.healthcare.gov/

Robert Woods Johnson Affordable Care Act information: http://www.rwjf.org/content/dam/farm/reports/issue_briefs/2011/rwjf71997

National Institute on Aging https://www.nia.nih.gov/

National Plan to Address Alzheimer’s Disease https://www.nia.nih.gov/alzheimers/publication/2012-2013-alzheimers-disease-progress-report/national-plan-address-alzheimers

President Obama announces the PMI https://obamawhitehouse.archives.gov/node/333101

President Obama and the Precision Medicine Initiative https://obamawhitehouse.archives.gov/the-press-office/2015/01/30/fact-sheet-president-obama-s-precision-medicine-initiative

All of Us Precision Medicine Initiative https://allofus.nih.gov/

Team Science  https://www.teamsciencetoolkit.cancer.gov/public/WhatisTS.aspx

Patient Centered Outcomes Research (PCORI) https://www.pcori.org/

Clinical trials https://clinicaltrials.gov/

Murphy, S. V. & Atala, A. (2014). 3-D bioprinting of tissues and organs. Nature Biotechnology, 32(8), 774-85. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25093879

Reichstadt, J., Sengupta, G., Depp, C. A., Palinkas, L. A., & Jeste, D. V. (2010). Older adults’ perspectives on successful aging: Qualitative interviews.  American Journal of Geriatric Psychology, 18(7). 567–575. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3593659/pdf/nihms213379.pdf

Bioprinter attribution:  Attribution not legally required.  From By Андрей Ильин [CC0 or CC0], via Wikimedia Commons. https://upload.wikimedia.org/wikipedia/commons/5/55/Printer_3D_Bioprinting_Solutions.jpg

Tissue printing schematic attribution:

Centromere121 (https://commons.wikimedia.org/wiki/File:Organ_printing_Step_1-2-3.png), Organ printing Step 1-2-3, https://creativecommons.org/licenses/by-sa/3.0/legalcode

Project ECHO—Share the Knowledge

William Hull RN, BSN

PhD Student, College of Nursing

University of Utah

Background  

Historically care is and has been delivered in primary care settings by primary care physicians. As healthcare has advanced and science has marched forward, heath care has become increasingly complex. This complexity has led to a fragmentation of medical knowledge as care has been delegated to a number of sub-specialties—gate keepers of advanced specialty treatment knowledge. This has created a complicated situation for many rural patients diagnosed with illnesses requiring specialty care. First, specialists may often have large patient loads and extensive wait times which can delay treatment and consultation, often for months. Furthermore, to receive care, these patients may have to drive long distances—at a cost of time, lost work, and pay. Then, depending on the diagnosis, patients may have to travel a number of times per month or year to receive appropriate care. Finally, in this model, patients interact with unknown physicians—void of prior relationships of trust. These barriers to receipt of optimal healthcare services in the current system, result in poorer health outcomes for rural patients.¹

Source: Blackbird Studios – Jodi Hull

Assumptions of the Existing Paradigm

Under the aforementioned primary care model, it is assumed that specialty care cannot be delivered without a specialist. In the model, the specialist holds the knowledge for treatment and acts as the gatekeeper. The assumption is that If care were to be delivered outside of the physician specialty model, treatment would be ineffective, subpar, and potentially detrimental to the patient.  

The Birth of Project ECHO

Dr. Sanjeev Arora and the University of Mexico health science center in Albuquerque observed this problem first hand in New Mexico. As a practicing Hepatologist, Dr. Arora had an eight month wait time for consultation with many of his patients driving 100-250 miles to be treated for Hepatitis C. Patients over the course of treatment made as many as 20 (average of 18) visits to academic medical centers resulting in many patient burdens, such as high travel cost, cost of specialty care consultation, and a loss of work time. Observing this problem, Dr. Arora developed project Extension for Community Healthcare Outcomes (ECHO).²

What is Project ECHO

Project ECHO utilizes teleconferencing technology to connect specialist with rural area physicians. Community based rural providers learn from specialists via “learning loops” as they co-manage patients utilizing the concepts of case based learning.³ ECHO enables rural providers with knowledge to treat complex patients with a variety of diseases that historically would be considered to fall outside of their scope of practice. In this regard ECHO departs from the standard telehealth model—the rural provider maintains stewardship of the patient as the specialist acts as a knowledge broker and mentor.⁴

Source: Blackbird Studios – Jodi Hull

Potential Impacts

The initial project ECHO for Hepatitis C demonstrated safe and effective treatment with equal cure rate to those treated at the academic medical center.² Other benefits to the patient include decreased cost of travel, decreased wait times, and care from a trusted and familiar provider. Further, aside from developed knowledge and demonstrated competence in managing patients requiring specialty care, rural care providers exhibited increased job satisfaction and reduced sense of professional isolation. These additional benefits may lead to better provider retention in rural areas.³ Today ECHO operates from 120 locations treating 60 conditions in 23 countries.⁵

Created Using Google Sheets and Project ECHO Location Information⁶

Why is this change necessary?

There is a worldwide shortage of specialty physicians. In New Mexico alone, there were 30,000 patients with hepatitis C with two specialty clinics in the entire state where these patients could receive treatment. Of these hepatitis C patients, only 1,600 were receiving treatment for chronic liver disease.¹  This is not an isolated problem only relevant to New Mexico and hepatitis C patients.  According to the Centers of Disease control and Prevention, currently 15% of the U.S. population live in rural areas. Furthermore, a recent CDC study demonstrated that rural Americans are more likely to die from potentially preventable disease than their urban counterparts.⁷

Barriers to adoption

Although ECHO has demonstrated promising results barriers exist to widespread implementation. These barriers include: lack of access to necessary technology, lack of reimbursement and/or financial incentives, and lack of provider time.⁸  Scott, J., et al., cited financial sustainability as a pivotal challenge in continuing the Project ECHO project in the northwest.³ This may be in part due to a lack of research that demonstrates fidelity for reproduction of the project in other locations. Furthermore, high-fidelity methodologies—randomized control trials—and further studies of cost effectiveness continue to be needed to measure the effectiveness of the project.⁸

Recommended readings/viewings:

https://www.youtube.com/watch?v=2lBfyOlL4_s

https://www.youtube.com/watch?v=lY5nlJxac0g

http://echo.unm.edu/about-echo/research/

References

1.         Arora S, Kalishman S, Thornton K, et al. Expanding access to hepatitis C virus treatment--Extension for Community Healthcare Outcomes (ECHO) project: disruptive innovation in specialty care. Hepatology. 2010;52(3):1124-1133.

2.         Arora S, Thornton K, Murata G, et al. Outcomes of treatment for hepatitis C virus infection by primary care providers. N Engl J Med. 2011;364(23):2199-2207.

3.         Scott JD, Unruh KT, Catlin MC, et al. Project ECHO: a model for complex, chronic care in the Pacific Northwest region of the United States. J Telemed Telecare. 2012;18(8):481-484.

4.         Arora S, Thornton K, Jenkusky S, Parish B, Scaletti JV. Project ECHO: Linking university specialists with rural prison-based clinicians to improve care for people with chronic hepatitis C in New Mexico. Public Health Reports. 2007;122(Supplement 2):74-77.

5.         UNM School of Medicine Project ECHO. Our story. 2017; http://echo.unm.edu/about-echo/our-story/. Accessed July, 13, 2017.

6.         UNM School of Medicine Project ECHO. ECHO Hubs & Superhubs: Global. 2017; https://echo.unm.edu/locations-2/echo-hubs-superhubs-global/. Accessed August, 1, 2017.

7.         Rural Americans at higher risk of death from five leading causes. Demographic, environmental, economic, social factors might be key to difference. 2017; https://www.cdc.gov/media/releases/2017/p0112-rural-death-risk.html. Accessed July 13, 2017, 2017.

8.         Zhou C, Crawford A, Serhal E, Kurdyak P, Sockalingam S. The Impact of Project ECHO on Participant and Patient Outcomes: A Systematic Review. Acad Med. 2016;91(10):1439-1461.