Just Read: Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention

Catching up on my reading…as this American Heart Association (@American_Heart) Scientific Statement was published in 2015, however it’s very exhaustive. And even more skeptical than I am about these things.

Remember when email came out and everyone thought that would revolutionize health? Then the Web came out and everyone thought that would revolutionize health? And then mobile devices….

Our review included a total of 69 studies that investigated the use of mobile technologies to reduce CVD risk behaviors, which included 10 RCTs targeting weight loss, 14 on increasing physical activity, 14 aiming to improve smoking cessation, 15 on blood glucose management, 13 on hypertension management, and only 3 targeting lipid management. The majority were RCTs.

A great part of the scientific statement and is resourcefulness is that in every area above, a good characterization of the problem is documented, with references. And then it goes into detail about what mobile health applications have been tested, what the results were, and what the gaps are.

There are a lot of gaps

For example:

Current commercially available mobile apps for smoking cessation have generally failed to deliver empirically supported interventions or to make optimal use of the capabilities of mobile phones. A series of studies by Abroms and colleagues have shown that most commercially available smoking cessation apps do not adhere to practice guidelines for smoking cessation.

This is in addition to the fact that there’s a significant publication lag – most of the studies published are not of actual mobile phone interventions, but of Internet/Web based ones.

Another theme running through what is known from the literature is that mobile health interventions don’t work on their own. They usually require a program surrounding them, or a system that leverages them.

This is sort of not new news, as I wrote about in this post in 2012: Now Reading: Does mobile technology support behavior change? Does it support weight loss?.

Looking more closely at hypertension (high blood pressure)

In the section on hypertension management, it’s interesting that 2 of these three successful trials mentioned:

All 3 of these studies provided some combination of patient educational resources, timely delivery of BP data to providers, and personalized messages to patients. The positive results of the 3 trials may suggest that a combination of such strategies or modes of intervention delivery may be needed to engage patients.

…were done in integrated health systems (Group Health Cooperative, Kaiser Permanente). I was an advisor on one of the studies and I have visited team that produced the second study (see: Day 3, Population Care, KP Colorado : Care gaps are the currency (and we want to go broke)).

In addition, they were done in places where high blood pressure control is higher than the national average.

The national average for blood pressure control is cited in the statement as a dismal/embarassing < 50%.

At Kaiser Permanente, it’s a health promoting/pride invoking > 90% (Yes, that is a 90% Hypertension Control Rate). Therefore the value of understanding mobile health interventions may be more ideal because a place where the system is working and mobile health can make it work more efficiently may show more promise than using mobile health to fix a broken system.

Other general issues cited

Many(most) published studies…

  • tend to not have control groups and enroll the willing/interested (the 10% problem)
  • are not long enough to show benefit for conditions that have to be managed for a lifetime (diabetes)
  • don’t follow established guidelines or make incorrect assumptions about what works in prevention (Education by itself doesn’t work)
  • are intervening around the wrong things – lipid management being a prime example – fortunately/unfortunately not much is being done in this area anyway (“The paucity of well-controlled trials for the use of mHealth interventions specifically for lipid disorders is remarkable, considering the prevalence of dyslipidemia in the general population.”)

The future, since 2010 – There’s still promise, I promise 🙂

I am aware that I wrote an oft-cited blog piece exuberantly promoting the promise of Mobile Health in 2010, in an cute listicle (6 Reasons why mHealth is different than eHealth).

I re-read the post it and I still agree with most of what it says (except the part where I say “piece of cake” – today it would be “piece of kale”).

mHealth is different than eHealth, which didn’t revolutionize health but evolved it, especially in places where health was part of the mission in the first place.

Where I work, for example, the accesses to our patient portal via mobile device have far surpassed accesses via desktop computers, since early 2015. I remember when just 20% mobile access was a huge deal. People are getting smarter about using evidence and modeling long term effects of shorter term interventions (I think and hope). And, especially in the nutrition/weight/lipid space, good questions are being asked around whether any intervention program should exist at all, and instead the current less-than-healthy program should be dismantled.

As I alluded to in my post reviewing the Apple Watch Series 2 (Review of Apple Watch Nike+, Fitness Tracking, and Heart Rate Variability), the penetration of mobile health applications in shaping and improving our health may be a combination of

  • The burning ambition of organizations making large investments (e.g. Apple)
  • High performing health systems who are already achieving health outcomes through system-ness and collaboration
  • Entrepreneurs and optimist-idealists stimulating all of the above
  • Listening to the people we serve

On the last bullet, this is still the decade of the patient, and the most important app of this decade is listening, which is sometimes in short supply, but getting better in my opinion.

On that note, don’t forget:

..it matters here as much as it does anywhere in health.

Speaker Academy #28: “It’s my job to be more interesting than your email” (@TedEytan) | e-Patient Dave

This post is part brag, part teach, part challenge. Last summer I did a webinar about patient engagement (here’s the replay) for Phreesia, a company that makes an iPad-like tablet that integrates a lot of steps to get you (the patient) into the provider’s computer system. Afterward, they said they “monitor the attention level of the attendees (it’s a GoToWebinar feature) … and it was the highest I’ve ever seen it.” Really? GoToWebinar feature?  Yep, the system keeps track of how long attendees stay, whether they ask questions, and even whether they listen but stop watching by switching to another window while listening to the audio. Sooo, I guess that means a lot of people kept watching and listening for the whole hour. Good! Because if they don’t pay attention they haven’t learned anything and the whole thing has been a waste. It’s hard to hold attention without seeing their faces. But it immediately reminded me of one of the most humble, wonderful,

Source: Speaker Academy #28: “It’s my job to be more interesting than your email” (@TedEytan) | e-Patient Dave

Really? Attention level? A lot of us who watch webinars are in trouble … 🙂

I think I gave @ePatientDave that quote a lot longer than 3 years ago, and I still believe it to this day. In fact, I enjoy it if people begin doing other things because then it’s experimentation time! When the first mobile device comes out I get official license to depart from any constraints made upon me in the interest of audience satisfaction and enjoyment.

On the converse, it’s a little depressing to watch another speaker continue on the same track once the devices come out. I guess the learning is that no one has unlimited access to a person’s attention just because of who they are or what they’re talking about. The corollary in the medical world is that patients get to choose whether to follow a physician’s advice. The corollary to that corollary is that almost every quality measure we use in health care today is based on patient choice (and the physician is accountable to support the patient in making the best choice).

I’m wondering to myself where this philosophy came from, and I think I know. I am used to being in and with audiences where people are not listened to, in a lecture hall, in a workplace, in society. Once you experience that for yourself or on behalf of another (or ask someone what that feels like), you’ll know the next step. If you want people to listen to you, start by listening to them. And that includes when they pull out their mobile device.

Such a wonderful benefit of technology. That and @ePatientDave.

Just Read: Listening means better patient outcomes

In my last post on listening ( see: Just Read: Just 6 more seconds of listening needed to elicit the patient’s agenda | Ted Eytan, MD ) I said I couldn’t find a newer study than 1999 … and then I met the author of this paper, Saul Weiner, MD, at the Center for Total Health (@KPTotalHealth) via an intro by Alan Spiro, MD (@AlanHSpiro), who it turns out is studying patient-physician communication, and steered me to this paper.

Cool technique: concealed recorders

As with the previous papers I reviewed, this study involved the audio recording of patient-physician visits, with a twist. With prior physician consent, patients were randomized to bring in a concealed recording device without the physician’s knowledge for a particular visit. I’m imagining a patient checking in for their doctor visit and then being approached by a research assistant to slip a recorder in their pocket. Patients do want to help if we let them 🙂 .

403 encounters were analyzed which contained a total of 548 “red flags” “including missed appointments; nonadherence with medications; poor control of a chronic condition, or lack of follow-through with laboratories, tests, or referrals.” Audio recordings were also screened for red flags (“Doc, I can’t afford these pills”).

What the researchers were ultimately able to discover after studying physician response to these red flags and following up in the patient chart was whether:

  • A context-senstive care plan was developed
  • An improved outcome was the result (more appointments made, better adherence to plan)

And….

patients with a contextualized care plan were more likely to have a positive outcome (odds ratio [OR], 3.7 [95% CI, 1.2 to 11.4]; P �� 0.021)…When the patient had seen the same resident at their most recent visit, they were more likely to have a positive outcome than when they had seen a differ- ent physician, regardless of whether the care plan was con- textualized (OR, 3.0 [CI, 1.0 to 8.9]; P �� 0.044).

It’s a little hard to visualize this with a chart since there are many dimensions; I did my best.

So there you have it, listening for 6 seconds longer elicits the patient’s agenda, and listening and planning in the context of the patient results in agendas with less problems down the road.

Just Read: Just 6 more seconds of listening needed to elicit the patient’s agenda

“…asking “Anything else?” repeatedly until a complete agenda has been identified appears to take 6 seconds longer than interviews in which the patient’s agenda is interrupted” Reference: Marvel MK, Epstein RM, Flowers K, Beckman HB. Soliciting the Patient’s Agenda: Have We Improved? Jama. 1999;281(3):283–287

Actually I read this a while ago; I realize I’ve never turned it into a slide, until now.

I’m using it to illustrate an artifact of physician culture, part of a keynote I’m preparing (Crowdsource Request: Keynote for Labor-Management Parntership all-hands – “Social innovation” | Ted Eytan, MD).

We tend to interrupt people. On average about 23 seconds into them telling us why they are here to see us. Good news is that it improved 5 seconds in between the 15 years it was studied (1984 and 1999). I can’t find a newer study, if anyone knows of one, let me know.

Interestingly, it was found that if physicians just listened for 6 seconds longer, by repeatedly asking “Anything else?” or “Tell me more?” they were able to know what the patient was concerned about. The opposite of this is not knowing up front, and the consequences of that – the door handle conversation, the “late concern,” the problem unexplored, and a less efficient encounter, and sometimes devastating health experience.

One interesting correlation is that physicians with fellowship training (training after residency) were more likely to exhibit listening behavior than those who didn’t have the training. These were all family medicine specialists so there’s no comparison of other specialties in this study.

This fits with what I have mentioned before in the world of listening, reducing conscious and unconscious bias, being there for the people we serve in and out of the exam room. The good news is it’s easy to move away from a “Yes I know what you’re asking for,” culture to a “tell me more” culture. I know because I do it all the time – “say more.” My colleague Danielle Cass (@DanielleCass) also taught me this one – “Go on..” Try replacing this response with the one you normally use and see what happens (and let me know what happens – magical!).

Listening is the hugest innovation in health in the decade of the patient.

6 seconds 🙂

Presentation: Why be Social (Media)? @BerkeleyISchool

I had the opportunity in 2013 to repeat what I got to do in 2011, which is lecture at the University of California School of Information (@BerkeleyISchool) in the following course: Info 290A. Finding Health in the US: Health Care and the Information Economy | School of Information

Below are the title slides from the 2013 lecture and the 2011 lecture. Notice how times have changed? If you do our you don’t please let me know in the comments.

2013 – “Our Cities are Changing”

2011 – “Social Media Creates Revolutions”

There’s a discussion and update on the latest data about social media use, and of course a clip of Regina Holliday (@ReginaHolliday) who is the perfect example of why social media should be used for listening as much as talking. Does that theme come across? 🙂

In terms of what I learned, this current class is mostly not using a lot of social media and definitely not using Twitter very much, which tracks with the national data (from the terrific @PewInternet ) that only 18% of Americans do. It’s a good reminder to social media enthusiasts that there’s a wide gap between the do and don’t.

Rest of the slides are below, enjoy. You can also access them full screen here.

A Walk about Walking with John Francis, PhD, National Geographic Fellow

Post-Walk with Dr. John Francis – View on Flickr.com

Walking is not just good for your muscles, your brain, and your heart – it connects you to exceptional people who are passionate about walking, too.

I am happy to say that my well-known love of the walk prompted John Francis, PhD‘s colleague Patti Brennan, PhD ( @pattifbrennan ) , to connect us when he was in Washington, DC last week, as part of a meeting of National Geographic Explorers Fellows Program.

Even though I read a little about his story before we met (walking, of course), I enjoyed him telling me about it himself, because it’s amazing. He spent 22 years of his life walking exclusively, and 17 years of not speaking, following the 1971 collision of two oil tankers in San Francisco Bay. He told me he realized that he wasn’t really listening to people – he was only formulating his next thoughts as he would argue about the choice to forgo motor vehicles. He’s written a book about his experience called Planetwalker, and you can read about that as well as listen to an interview of him on the National Geographic site as well as on Wikipedia. He’s been speaking since 1990.

He’s recently taken a group of students on a walk across Ohio and is planning an entire learning curriculum that’s based on walking and appreciating / observing everything in our environment. I felt a sense of camaraderie as I had a camera in my hand, which is often the case when I’m walking.

I’m posting information about John’s story here because I’m impressed by his work, I think you’ll be too, and impressed with the commitment he’s made to respecting people and the environment through listening, observing, and walking. Come join the walking revolution if you haven’t already.