With chronic illness, a monitored patient is a healthier patient, and there are plenty of ways to do it, based on initiatives popping up around the country. In Louisiana, Michigan, Illinois, Maryland and elsewhere, the use of mobile devices ranging from cellphones to computer tablets are enabling patients with diabetes to control blood sugar and patients with heart failure to watch their sudden weight gain.
The starting point for a chronic illness management initiative affects the choice of mobile tool. In New Orleans and metropolitan Detroit, two federally funded Beacon Community projects sought to identify people who were at risk for diabetes, but saw a doctor infrequently or not at all. A text message application on their cellphones helped them to understand the seriousness of their condition. In Maryland and Rockford, Ill., mobile devices were used to monitor the vital signs of patients already identified with chronic conditions and help them to adhere to treatment plans.
One common aim was to limit the use of highly paid clinicians through electronic patient monitoring and electronic interaction, with occasional contact by other staff with appropriate training. At University of Chicago Medicine, an automated texting program cut nearly 1 percentage point on average from blood sugar readings and nearly 2 points for people with poorly controlled diabetes. Only about 5 percent of patient responses needed to go as far as a physician for action. "I think we could scale this in environments where there is no tieback to the physician and we'd still capture 90-plus percent of the benefits," says Shantanu Nundy, M.D., one of the pilot leaders.
The impact of mHealth on chronic disease management takes many forms:
In New Orleans and Detroit, an application called txt4health was advertised broadly through television and radio, social media and online advertising. People could enroll by texting "health" to a text address. After completing a diabetes assessment, they were placed in a risk category that determined which tailored messages were pushed out to them, four to seven per week. The main objective was "creating greater awareness of the condition, and prodding people to acknowledge it may be something they might have," says Alison Rein, senior director for evidence generation and translation at AcademyHealth, which conducted the Beacon studies. "Then, if they do have it, to be more conscious of the risk factors and consequences of not managing it." Results are pending, but the programs have logged lessons on orienting people to the tools and aims.
In Chicago, the monitoring focused on behaviors, not the clinical situations. For instance, they monitored whether a patient checked blood sugar rather than the result, or whether a medication was causing a problem, instead of the particular side effect. Operationally, it meant health coaches could wait as much as a day to respond to basic needs, such as refills or a reading out of range, Nundy says. Using a simple structured assessment, a coach would collect information from a patient by text or phone and either resolve a need immediately or bring in a physician [see first case study].
In Maryland, a test of mobile monitoring and coaching led to a 1.9 percent reduction in sugar levels over a one-year period using a system called BlueStar, from Baltimore-based WellDoc. A patient enters readings and gets automated information that helps with self-management, says Chris Bergstrom, chief strategy and commercial officer. Through a "clinical/behavioral expert system" loaded with medical history, medication regimens and physician orders, the information is personalized and is contextually relevant to the individual, Bergstrom says. Physicians periodically get a report summarizing what a patient has struggled with, plus treatment suggestions based on clinical evidence.
In Illinois, the Visiting Nurses Association of Rockford reduced readmission rates of patients with congestive heart failure discharged from Rockford Memorial Hospital by using telehealth monitors with a weight scale, blood pressure cuff and pulse oximetry device from Honeywell HomMed. A pilot began in November 2012 and currently more than 80 monitors are available for use. Readmission for all causes was 9 percent, says David Taylor, R.N., supervisor of telehealth services, VNA of Rockford, adding that "early recognition, early treatment kept people out of the hospital." [See second case study.]
"Do you need a refill?" That question was texted every month to all patients in the University of Chicago diabetes initiative. If patients responded, "Yes," an outreach health coach would take care of it instead of the patients' having to call a doctor and wait on hold, says Nundy.
Patients were asked routinely how many times they took their meds the past week. If they responded five days or fewer, it would alert a coach to call. And if the response rate to any periodic question dropped more than 20 percent from one week to the next, it generated a call.
Some of the most perceptive reactions by coaches had to do with what patients weren't saying.
One woman who loved the service and was always texting back, stopped completely for a week. She got a call, and told the coach she was spending most of her time in the intensive care unit with a stricken sister. It was understandable why she wasn't responding, Nundy says. "So the nurse says, 'Hey, by the way, how's your diabetes doing?' And there's a pause. The patient [admits], 'I haven't taken my medication in a week, since my sister was admitted.' It turned out that this patient was a type 1 diabetic, on insulin, so the nurse in the ICU checked her blood sugar and it was sky high."
With a 30-day readmission rate of 25 percent for patients with CHF, Rockford Memorial needed to follow those patients home in some way, but it couldn't use nurses from the local VNA. Under Medicare guidelines, only homebound patients who needed skilled nursing and were unable to drive were eligible for home care, says the VNA's Taylor.
But the VNA could set up a monitor in those patients' homes, obtain and analyze the readings, and share the data with the Heart and Vascular Center, the hospital's cardiology medical group, Taylor says. Then it was up to nurse practitioners or cardiologists to act on the information they were getting. After a six-month pilot, "we never stopped it, we just kept going, because we'd seen such good results as far as decreasing readmissions," he says.
Not all patients with CHF were discharged with a monitor. Some were not followed by the cardiology group that participated in the initiative, or some had no cardiologist of record. "If that patient had an issue, we had nobody to call to act on it," Taylor explains.•
WHAT WORKS: Factors critical to successful community mHealth
• Identify community partners willing to support the program; leverage their resources and community presence to reach target audience.
• To the extent possible, design outreach, enrollment and message content around needs and perspectives of end users.
• Anticipate that traditional marketing tactics may not be sufficient to drive enrollment; plan for additional staff time, resources for in-person engagement.
• To the extent feasible, bring providers into the process to help them understand and promote mHealth as a tool to enhance care.
• Decide at the outset which aspects of the program are critical to measure and which are not.
Source: Considerations for Community-Based mHealth Initiatives: Insights from Three Beacon Communities, Journal of Medical Internet Research, 2013.