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.

Now Reading: Another way to listen, Video Ethnography

This paper, published by esteemed colleagues at the Kaiser Permanente Care Management Institute, describes results from a program that now includes 37 teams and 130 people, who have engaged in in-depth training to understand the real experience of patients and those who care for them using video:

This method is particularly effective in helping increase understanding of vulnerable people who are not well represented in ap- proaches such as focus groups and patient advi- sory councils—for instance, frail elders, patients nearing the end of life, and those with multiple chronic conditions. Video ethnography also helps in focusing on pivotal points in health care, such as transitions between settings.4

This is a real technique that complements work to involve patients in the design and operation of the health care system. I have previously posted the link to the CMI Video Ethnography Toolkit – you can find out more about this here: Now Reading: Getting Started in Video Ethnography – Tool Kit – Kaiser Permanente Care Management Institute | Ted Eytan, MD.

Showing a video of the patient experience does not replace involving patients in other ways, however it does bring information that doesn’t come from other traditional sources. In the paper, work to uncover why medication reconciliation was not as effective as it could be, even in a system with a comprehensive electronic health record is described. A dose of reality is contained within, which is that an EHR is not enough – the ability to lead, and listen must come along with it.

Medication reconciliation at patients’ homes, in which home health nurses tried to verify pa- tients’ medication lists, was inconsistent and not comprehensive. Discharge instructions often lacked specific details. Home health nurses were unable to access Kaiser Permanente’s electronic health records while in patients’ homes and did not have a definitive list for medication reconciliation.

In a post-EHR health care organization, which hopefully the entire United States health system will be one day, the need to learn faster will never stop.

At Kaiser Permanente, we use video ethnography at various stages of the quality improvement process to identify care gaps, unmet patient and caregiver needs, and effective practices. We also use it to communicate insights to clinical and administrative organizational leaders, identify improvement opportunities, and help build collective will for change.

Here’s a link to the press release with a short video about this work: Kaiser Permanente Finds Videotaping Care can Produce Rapid Quality Improvement | Kaiser Permanente News Center

Take a look. I hope to enroll as a student this summer in a Kaiser Permanente video ethnography course, it’s my last chance in the 2012 training season. Listening can’t be beat.

Now Reading: Yikes! What physicians in training don’t ask patients admitted to the hospital

The hospital can be a very scary place, and when I read this study, I immediately thought that it would bring to life the worst fears of our patients, their families, and their doctors too.

The paper describes structured observations of PGY-1 and PGY-2 (first and second year out of medical school physicians-in-training) doing initial history and physical examinations of patients in the hospital.

As the title says, the study was “single-blinded” – the physicians observed did not know what they were being observed for, just that they were being observed (consent was obtained from both the patients and the physicians).

And… while patients were asked 100% of the time what medications they were taking (score for medication reconciliation), they were asked what they did for a living 4% of the time, level of education 0 % of the time, and from 0 to 100% of a list of other important pieces of information. Same general trends were seen in physical exam performance. Take a look at the charts by clicking on the link above and see what thing you would want your doctor to know if you were put in the hospital wasn’t asked.

Average time observed doing physicals and history: 7.3 minutes for history, 5.29 minutes for physicals, average time claimed in a survey of the doctors: 28 minutes and 15 minutes respectively . Huge discrepancy.

36% of the time, the physicians did not introduce themselves to the patient.

72% of the time, the physicians did not explain what they were there to do.

Remember, this is admission to the hospital.

“Unclear what the most effective approach would be to change these behaviors”

This is the ominous sounding statement made in the discussion by the author, who appropriately conveys his dissatisfaction with these results, and the fact that the physicians have been taught what the right things are to do.

From my own experience, I believe him. The issue isn’t knowing what to do. In my own training, I didn’t explore the patient and family experience as much as I should have. My residency faculty really helped me with that. At the same time, they were under tremendous pressure to balance educational requirements, the needs of patients getting care, and the needs of their fellow physicians and nurses that they recruited to participate in our teaching. Sometimes this balance was not balanced in a stressful environment.

Could we recruit patients and families also?

As much as we recruit quality faculty to teach residents, couldn’t we recruit patients and families, too?

It’s a familiar experience after a resident takes care of a patient in the hospital to be asked by the patient if they can join the resident’s practice. What would it be like if each resident needed to recruit 1-3 patients that they took care of to become part of THEIR (the resident’s) care team? Imagine them asking one of their patients or their family on discharge, “Mrs. Smith, as part of my training, I need to have 3 patient advisors who will help supervise my training, would you be available?”

Interestingly, an example of the clarity that patients bring to a physician’s development at any stage of practice-life comes in the same issue of The Permanente Journal, from a patient with an adverse outcome (“Bridging Physician-Patient Perspectives Following an Adverse Medical Outcome

Until my mother went through this experience, it never occurred to me how much medical professionals ask of us. Our family was asked to entrust the care of our loved one to strangers, her life and health to a system that sometimes creates barriers for the sake of efficiency. Then in the face of an error we are expected to stay quiet and accept this devastating impact on our loved one.

This article speaks about the HealthCare Ombudsman/Mediator Program at Kaiser Permanente, which brings patients and physicians together to resolve communication, quality, and trust issues. In the same article, a physician who discloses a surgical error carefully to a patient and their family says:

This process of explaining myself, opening me up to colleague scrutiny and patient disappointment, was by no means easy. Nevertheless, I know the price paid was infinitely less than living with the thought I had caused harm to a patient and did nothing to remedy it with a truthful disclosure and a heartfelt apology.

and

Thereafter, I followed-up with my patient and her family, explaining the systemic changes made to prevent a wrong part from ever being introduced during a surgical procedure.

Could some of these people, during and after their healing, serve as advisors/coaches/guardian angels of our future physicians as they learn their craft? They (the patients) are who I see as my guardian angels today – this just speeds up that journey.

Is this farfetched, is this happening somewhere already? What are the nuances? Please post in the comments

Studying leadership at pepper-spray-less Occupy DC

I have been wondering why California Occupy camps have been igniting in violence and conflict, while Washington, DC’s camp ( @occupy_DC @occupyKst ) seems to coexist peacefully with the surrounding community. These two outcomes make me curious about leadership.

There’s no pepper spray here, the camp is 53 days old today, the first time I walked through it (it’s in the middle of the city) I was immediately amazed. It feels like a community, it is hard to explain. There’s actually a dentist’s office on site, with community dentists providing care on the weekends. There’s a kitchen, of course, and there’s sanitation – and this is where differences start to emerge.

It appears that the National Park Service, with responsibility for McPherson Square, made the decision to engage with the residents here. You can see posted signs informing them of proper sanitation procedures, along with portable toilets, adorned with signs by residents urging clean habitation (see photos below). There is a police presence nearby, but no conflict.

I found some articles that describe the differences, including the conscious decision by the City Council to engage, rather than fight, the residents. The space itself is in a relatively unused part of the city and the camp actually brings activity to a place that formerly had very little. There’s even some urban planning going on within the Square.

I recorded an announcement a few days ago, by a resident who had approached local Metropolitan Police Department leadership to clarify behavior that had been seen, and the response provided was, “Thanks for telling us,” and no conflict.

Yesterday I asked one of the residents if my hunches were correct. She said she has noticed increased police presence, but there has not been conflict. I asked about health care. She said there was a medical tent right behind us. You can see the list of needs on the board, which includes an Automated External Defibrillator – they are thinking safety. I asked if anything was not going well. She said, “This weather” (it was raining). We were interrupted at that point by a human mic announcing that the DC Department of Health was coming to do a health inspection. All of this happened while we were standing in front of an Information tent, where information was being given out (just like it said).

I think it’s great to have an example, here in Washington, DC, of a different kind of leadership in an environment of dissent. Here, the results are less conflict, more collaboration, less harm, more speech, less failure, more success. For now. Also, less press coverage. I hadn’t seen these differences written about, so I decided to create this post.

From a leadership perspective, I think the Occupy movement may well result in a few textbooks (or whatever format knowledge will be in in the future) being written about how to lead.

As usual, I see many analogies to health care (and life in general).

Photos of the above plus links to the articles cited are below. Click to enlarge. Let me know what you think.

Brave and Obsessed, my visit to @Elizacorp, Beverly, Mass

I have been a huge fan of Alex Drane – and hugely curious. Everything from how she has a sense of humor in health care to what she’s learned about what inspires and motivates people. So when I had the chance to spend some time with her and team at Eliza Corporation, I took it!

Eliza’s name doesn’t come from the (in)famous artificial intelligence program from the 1980’s (or before?), it comes from Eliza Doolittle – you can tell from my photographs of the office that Audrey and Eliza are everywhere. What Eliza does in health care is to have conversations with people about things of importance using advanced speech recognition technology. That’s the generic version. The specifics are very interesting here.

First of all the “things of importance” are more likely to be the things that people think are important in their health, which is often not the same thing that health care organizations think is important in their health. It could be having a satisfying job more than having a satisfying hemoglobin a1c level. Not being in debt versus not being overweight.

Second, the conversations are not “voice-talent” issued conversations about facts, and costs, and benefits, they are real people voices engaging creatively with language and tone, talking about how statin drugs miss their users and how a high cholesterol is like a headache that affects your whole body.

Eliza has a 400 million call database, and they learn from the scars caused by the responses of people caught in frustration, off guard, or through the irrelevance of poorly written voice scripts. Alex played a few example recorded calls. No question that these will help an organization learn. quickly.

In my tweetstream (which I affectionately hashtag’d #NXNE with respect to my SXSW-attending friends), I referred to Eliza as the repo-men (persons) of health care – they are not typically asked to engage the engaged, they work with the least engaged, working to bring them back into care. This may mean using advanced techniques to reach the most disengaged via privacy-appropriate messages left on family voice mail.

This is an interesting corner of our health system, a place where people understand:

  • attitude is everything, and that the mentionables that we are trained to ask about in health care come with a lot of unmentionables, that may be far more engaging to the people we serve
  • amazing technology exists to solve every health problem, yet health problems are not solved
  • working with the disengaged is a great place to learn

Think about this one – what if a health system realized that consumer debt was tied to weight gain, so instead of setting up a weight management program, it set up a debt management program (or partnered with an organization that services debt) and generated weight loss through debt loss? This is not as farfetched as it might sound, especially if you watch Suze Orman, who has noted a 2 pound weight gain for every $1,000 of hidden debt in her work.

There’s a lot of people working in the field of engagement who can show success from new technologies, maybe in the short term, maybe with a subset of people who are ready to be successful. Eliza seems different, they’ve been doing this for a really long time, have been adjusting their approach, and haven’t been going to the people who would otherwise come to them. Maybe one day Eliza will create an engagement bootcamp, to teach others about the science and the art of of being inspiring. It seems to me this requires strong leadership AND a willingness to learn and grow, or in Alex’s words, to be brave and obsessed….

Photos below, click to enlarge, and don’t be fooled by the spartan surroundings, they walked me through the server room – 400 million calls worth of engaging computers…..