Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations PDF

Mount Saint Vincent College Access Provided by: Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations, 2e Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations Courtney R. Lyles; Dean Schillinger; John D. Piette OBJECTIVES Objectives Describe the rationale for using interactive mobile health (mHealth) technologies as an adjunct to the care of socioeconomically vulnerable patients, both in the United States and abroad. Review potential uses of mHealth in chronic illness care. Review the evidence for the effectiveness of mHealth in chronic illness care. Describe the characteristics of patients best suited to use mHealth as part of their care. Review the use of mHealth as a method of improving communication between providers of health care (inpatient and outpatient; community and health system). Jason, a patient with active human immunodeficiency virus (HIV) and occasional cocaine use, has difficulty adhering to the multipill HIV regimen. He enrolls in a novel webbased program in which he is equipped with a text pager that reminds him when and how to take his medications and prompts him to enter simple adherence data. If he does not respond or reports poor adherence, his case manager attempts to connect with him either in person or by phone. Several months after enrollment in the program, his viral load drops to the undetectable level. Innovative methods to educate patients and providers, promote adherence, and enhance communication both between patients and providers and among providers across different settings have become available through the growth of computerbased technologies. Interactive web or mobile phonebased programs are often broadly referred to as mobile health or “mHealth,” a term that we will use here to encompass any patientfacing computerized health technology. Examples of mHealth include systems that monitor patients’ progress toward physical activity goals, assess risk of disease, remind patients to take medications, or provide the information patients need for more informed decision making. While most patients with chronic diseases struggle with selfcare, innovations such as these may have the greatest impact on improving the care of vulnerable patients, who often face barriers to accessing health information and support via facetoface encounters with clinicians and other helpful social network members. Access to the Internet is becoming commonplace. Recent surveys by the Pew Research Center report that 85% of Americans use the Internet and 91% have mobile phones (including 56% who have smartphones with Internet access).1 Most importantly, the differences in Internet and mobile phone use by race/ethnicity and socioeconomic status have been shrinking rapidly. Similarly, there has been an explosion in the use of mHealth technology in healthcare settings, such as the introduction of personal electronic health records for patients and the availability of thousands of mobile phone applications for managing a wide range of health and healthcare topics. Even when examining the uptake of technology internationally, it is clear that the digital divide is shrinking between low and highincome countries as well, with mobile phone coverage and use growing quickly worldwide. In fact, many of the lessons learned from implementing technology interventions in low and middleincome countries are particularly informative for improving the health and health care of vulnerable patients in the United States.2,3 Downloaded 9:30and A mobile Your IPphones is 63.247.225.21 While the use 2024218 of the Internet continues to climb, the frequency and type of technology access can differ among lowincome Page Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations, R.inLyles; Dean Schillinger; John 1D./ 18 patients, especially when considering Smartphone ownership and broadband Internet access. UnlessCourtney these gaps technology access are addressed, Piette information toolsHill. thatAllrequire computer use will continue present challenges for socioeconomically vulnerable ©2024 McGraw Rightspersonal Reserved. TermsorofSmartphone Use Privacy Policy Notice to Accessibility communities. healthcare settings, such as the introduction of personal electronic health records for patients and the availability of thousands of mobile phone applications for managing a wide range of health and healthcare topics. Even when examining the uptake of technology internationally, it is clear that Mount Saint Vincent College the digital divide is shrinking between low and highincome countries as well, with mobile phone coverage and use growing quickly worldwide. In fact, Access Provided by: many of the lessons learned from implementing technology interventions in low and middleincome countries are particularly informative for improving the health and health care of vulnerable patients in the United States.2,3 While the use of the Internet and mobile phones continues to climb, the frequency and type of technology access can differ among lowincome patients, especially when considering Smartphone ownership and broadband Internet access. Unless these gaps in technology access are addressed, information tools that require personal computer or Smartphone use will continue to present challenges for socioeconomically vulnerable communities. In addition, socioeconomically vulnerable patients often have limited health literacy,4 limited English proficiency, or other communication challenges that serve as formidable barriers to the use of most standard mHealth services. Consequently, these patients may have difficulty accessing “offthe shelf” mHealth solutions, even when those technologies have proved beneficial for other patient groups. A recent review of the evidence found that studies reporting on the usability of diabetes Internet and mobile phone applications rarely addressed issues of accessibility for diverse or vulnerable patients.5 Despite these potential barriers, safetynet health systems striving to improve treatment access and quality can use mHealth successfully if careful attention is given to how those services are designed.6 This chapter discusses the principles that should drive the design and development of mHealth services so that they are accessible and effective in diverse populations of patients. The focus is primarily on the use of mHealth to promote more effective communication and disease management among patients with chronic health problems, such as diabetes, heart failure, or depression. These patients represent the majority of visits and uncompensated healthcare costs within safetynet heath systems. Such patients often lack the resources required to manage their condition successfully, and access barriers significantly add to the difficulty of meeting the demands of their illness. Rather than focus on specific types of mHealth technology (such as webbased applications or interactive voice response systems), the chapter focuses on concepts that are relevant for most currently available technologic platforms. Each healthcare system must choose the appropriate platform for delivering the health technology programs outlined below—whether it be texting, automated telephone calls, clinicbased multimedia supports, or other webbased programs. Matching existing technologies to the skills and capacity of both the patient population and current care processes within the healthcare setting will best utilize mHealth solutions to address gaps in care. THE FUNCTIONS OF INTERACTIVE HEALTH TECHNOLOGIES IN CHRONIC ILLNESS CARE When implemented effectively, mHealth can be helpful in redressing the difficulties faced by safetynet healthcare systems and the patients they serve. Financial access barriers, geographic distance, language barriers, long waiting times, and restrictive work schedules all conspire to make typical face toface communication within outpatient settings especially difficult for socioeconomically vulnerable patients.7 In general, mHealth technologies can assist patients to get support managing their chronic conditions either through direct communication with providers or access to relevant health and selfmanagement information. Many chronically ill patients may need weekly or even daily support for their selfcare; however, such demands strain even the most effective care management systems and are impossible to meet by most safetynet providers. Many patients within safetynet health care systems are complex and often have multiple chronic comorbidities which make the prioritization of discussion topics with their provider even more challenging.8,9 Despite the obvious importance of clinician–patient communication, healthcare providers often are unaware of patients’ self management goals10 or the financial pressures that patients struggle with because of their treatment,11,12 issues that may be clarified and communicated to the provider through mHealth programs. Many mHealthbased disease management interventions (particularly those developed in the early 1990s) attempted to address multiple self management problems simultaneously. Earlier enthusiasts of these new technologies seemed to operate based on the expectation that (because they were so novel and exciting) technologybased interventions per se would have a therapeutic benefit, and therefore careful consideration of intervention goals was less important. However, like all clinical services, mHealthbased services are most effective when they are designed with specific, targeted goals in mind (Box 171). Box 171. mHealth Goals for Chronically Ill Patients Assisting patients with administrative tasks (e.g., remembering when followup visits are scheduled). Ongoing patient monitoring and surveillance to identify health and behavioral problems. Delivering patient education or other information to assist in disease selfmanagement, including personalized feedback on selfcare behaviors. Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Facilitating informal support (e.g., Health peer support) for coping with illness. Chapter 17: Applying Interactive Mobile (mHealth) Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John 2D./ 18 Piette ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility USING MHEALTH TECHNOLOGIES TO SUPPORT ADMINISTRATIVE PROCESSES OF CARE management problems simultaneously. Earlier enthusiasts of these new technologies seemed to operate based on the expectation that (because they Mount Saint Vincent College were so novel and exciting) technologybased interventions per se would have a therapeutic benefit, and therefore careful consideration of Access Provided by: intervention goals was less important. However, like all clinical services, mHealthbased services are most effective when they are designed with specific, targeted goals in mind (Box 171). Box 171. mHealth Goals for Chronically Ill Patients Assisting patients with administrative tasks (e.g., remembering when followup visits are scheduled). Ongoing patient monitoring and surveillance to identify health and behavioral problems. Delivering patient education or other information to assist in disease selfmanagement, including personalized feedback on selfcare behaviors. Facilitating informal support (e.g., peer support) for coping with illness. USING MHEALTH TECHNOLOGIES TO SUPPORT ADMINISTRATIVE PROCESSES OF CARE Ms. Sepulveda, a 53yearold Spanishspeaking woman, has diabetes and hypertension with persistently elevated hemoglobin A1c and blood pressure. Her prescription for a glucometer has been denied at her usual neighborhood pharmacy because of changes in her insurance coverage. With her son’s help, she recently registered for access to an online patient portal to be able to view her medical record information on a secure website. Through the portal, she and her son are able to email her primary care team to inquire about the glucometer. The medical assistant who responds to the email provides information about obtaining diabetes supplies via the hospital pharmacy and checks in with Ms. Sepulveda about her remaining refills for her other diabetes medications. Chronically ill patients face a daunting task when managing their health problems: handling numerous medications, coordinating repeated visits to different clinicians, and navigating the continually changing requirements for insurance or benefits. Even those with insurance can be financially strained by the costs of treatments and medications. Studies indicate that chronically ill patients have difficulty meeting these administrative challenges, particularly if they have little education or limited English proficiency. Patients often miss scheduled appointments, and noshow rates are often highest among individuals with the greatest need for clinical care.13 More than onethird of diabetes patients with either no health insurance or Medicaid coverage reported forgoing prescription drug use in the prior year because of cost concerns, despite the fact that those patients were almost universally eligible for firstdollar medication coverage through state and regional financial assistance programs.12 mHealth programs can assist patients managing the complexity of their health service use as well as their selfcare. Automated reminder calls delivered via a computerized “interactive voice response” (IVR) telephone system to patients undergoing medication treatment for tuberculosis increased visit attendance rates relative to controls.14 Even though patients were not aware that IVR reminders would be coming to their homes, the calls were effective for patients with a variety of primary languages, including Mandarin, Vietnamese, Tagalog, and Spanish. Other studies have found that automated reminders can increase attendance rates for routine vaccinations15 and can assist patients in taking their medications as prescribed.16 Importantly, “lowtech” alternatives to automated telephone calls (such as reminder letters) also improve attendance rates,17 but IVR reminders are costeffective when compared with these more laborintensive alternatives. High patient engagement with IVR technologies has also been documented in low and middleincome countries, suggesting that this approach for chronic disease selfmanagement support is adaptable for diverse patient populations.2,3,18 The technology used to deliver IVR reminders is relatively simple and inexpensive (especially with the increased ability to employ very lowcost voice over IP (VoIP) technology to deliver the calls),19 and the research in this area is sufficiently definitive that safetynet providers should consider incorporating such reminders into usual outpatient care. Other forms of mHealth, such as text messaging to cell phones, may be effective in assisting vulnerable patients with the administrative functions of their disease management. Recent systematic reviews have found that texting can significantly improve appointment adherence and selfefficacy for chronic disease selfmanagement, but there is far less evidence that such interventions can improve clinical outcomes such as glycemic or blood pressure control or weight loss.20,21 In addition, texting programs have been shown to improve smoking cessation rates.22 However, there have been fewer studies of texting conducted in socioeconomically vulnerable patient populations. Among patients in one safetynet system in Chicago, patients reported high satisfaction rates with texting programs for medication reminders, as well as selfreported improvements in medication adherence and 23 overall confidence in diabetes selfmanagement. Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John 3D./ 18 Finally, Piette the introduction of personal electronic health records, or patient portals, may assist patients in managing the administrative tasks associated ©2024 McGraw All Rights Terms Use patients Privacy Policy Notice Accessibility with their chronicHill. illness care.24Reserved. These systems can of provide with access to a variety of functions associated with their care: from secure email with providers and staff; viewing visit summaries, lab results, and medical histories; and online appointment scheduling and refill requests. Studies in their disease management. Recent systematic reviews have found that texting can significantly improve appointment adherence and selfefficacy for chronic disease selfmanagement, but there is far less evidence that such interventions can improve clinical outcomes such as glycemic or bloodCollege Mount Saint Vincent Providedthere by: pressure control or weight loss.20,21 In addition, texting programs have been shown to improve smoking cessation rates.22Access However, have been fewer studies of texting conducted in socioeconomically vulnerable patient populations. Among patients in one safetynet system in Chicago, patients reported high satisfaction rates with texting programs for medication reminders, as well as selfreported improvements in medication adherence and overall confidence in diabetes selfmanagement.23 Finally, the introduction of personal electronic health records, or patient portals, may assist patients in managing the administrative tasks associated with their chronic illness care.24 These systems can provide patients with access to a variety of functions associated with their care: from secure email with providers and staff; viewing visit summaries, lab results, and medical histories; and online appointment scheduling and refill requests. Studies in large delivery systems such as Kaiser, Group Health, and Cleveland Clinic have reported that patients with access to portals are more likely to have improved diabetes control,25,26,27 suggesting that the convenience of completing several administrative tasks may be linked to better outcomes. Patient access portals or secure emailing with providers has been more limited in safetynet systems, but there is high interest in electronic communication with healthcare providers among this patient population.28,29 The introduction of portals into safetynet settings in the next few years with US health reform will provide a wealth of opportunities for evaluating their potential.30,31,32 USING MHEALTH TECHNOLOGIES FOR ONGOING PATIENT MONITORING Mr. Yu, a 65yearold Cantonesespeaking man with diabetes, is a participant in a diabetes program that uses an automated telephone outreach system. His response during an IVR monitoring call triggers a nurse callback about a foot problem, and he describes blisters on his right foot. He had recently increased his walking in shoes that no longer fit well. Mr. Yu had continued to walk despite the discomfort because “his doctor told him how important walking was for controlling diabetes.” The nurse scheduled Mr. Yu to see the podiatrist to reassess shoe fit, and he was fully evaluated and given new shoes within 3 weeks. Most patient monitoring occurs as reactive care during relatively infrequent facetoface outpatient visits. Few health systems have the information systems needed to trigger a proactive and comprehensive assessment when patients seek care through different entry points (e.g., an emergency department), and many patients have difficulty keeping scheduled office visits.33 Consequently, chronic disease treatment plans often reflect patients’ historical problems more than their current needs, opportunities to prevent health crises are missed, and educational efforts lack the timeliness needed to be effective. mHealth can assist clinicians in gathering uptodate information about patients’ health status and behavioral needs. For example, lowincome patients with diabetes in the United States and abroad can and will complete brief IVR assessments of their glucose selfmonitoring values and self management behaviors.34,35 Engagement is also high across a variety of healthcare conditions, such as programs for heart failure, cancer, diabetes, and depression. These applications appear to be especially useful for patients with limited English proficiency.36,37 IVR data are often reliable even when reported by individuals with psychiatric disorders.38 Such assessments can accurately triage patients into groups with high, medium, and low risk for adverse outcomes. A rapidly growing area of technology development has been the design and testing of remote monitoring applications that can track patients’ clinical data without relying on patients’ selfreports. A recent randomized trial of veterans with back pain found that pedometers that uploaded physical activity to a website with personalized walking goals, feedback, motivational support, and social support resulted in greater decreases in painrelated disability.39 Incorporating external device information from glucometers and blood pressure cuffs uploaded into mobile phone applications or websites can be particularly appealing if passive data capture provides both more accurate and larger amounts of data to understand a more complete picture of selfmanagement. A randomized controlled trial of telemedicine with remote monitoring of blood pressure and blood glucose among low income Medicare patients in New York found significant improvements in A1c, blood pressure, and lowdensity lipoprotein control.40 Similarly, patients with hypertension receiving IVR automated telephone selfmanagement support with home blood pressure monitoring in Honduras and Mexico also showed improved blood pressure control, reduced medication nonadherence, better overall health status, and higher satisfaction with care.41 Careful consideration must be given to the ways in which health systems respond to mHealthreported information. While the effectiveness of such systems has been documented, there are a range of issues related to implementation into an existing clinical setting, such as willingness of staff and providers to use the technology and new data sources.42 Clinicbased “case finding” or screening with feedback to providers can have little impact on patient outcomes,43,44 often because providers have limited ability to change practice patterns or because treatment changes are not tightly linked with health outcomes. Providers who are pressed for time or treat patients with multiple urgent complaints often lack the resources required to follow Downloaded 2024218 9:30 A Your IP is 63.247.225.21 up effectively on serious, but chronic patient needs (e.g., dysthymia, functional limitations, or selfmanagement problems). mHealthbased patient Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John 4D./ 18 monitoring with limited clinical s pecificity may generate unnecessary outpatient visits, straining scarce resources in public clinics, and indirectly Piette denyingMcGraw access toHill. other with acute health Given the state of the science in mHealth patient monitoring, s afetynet p roviders should ©2024 All patients Rights Reserved. Termsconcerns. of Use Privacy Policy Notice Accessibility carefully consider the frequency and content of mHealth assessments, and the implications of both erroneously identifying patients as having serious Careful consideration must be given to the ways in which health systems respond to mHealthreported information. WhileMount the effectiveness of such Saint Vincent College systems has been documented, there are a range of issues related to implementation into an existing clinical setting, suchAccess as willingness Provided by: of staff and providers to use the technology and new data sources.42 Clinicbased “case finding” or screening with feedback to providers can have little impact on patient outcomes,43,44 often because providers have limited ability to change practice patterns or because treatment changes are not tightly linked with health outcomes. Providers who are pressed for time or treat patients with multiple urgent complaints often lack the resources required to follow up effectively on serious, but chronic patient needs (e.g., dysthymia, functional limitations, or selfmanagement problems). mHealthbased patient monitoring with limited clinical s pecificity may generate unnecessary outpatient visits, straining scarce resources in public clinics, and indirectly denying access to other patients with acute health concerns. Given the state of the science in mHealth patient monitoring, s afetynet p roviders should carefully consider the frequency and content of mHealth assessments, and the implications of both erroneously identifying patients as having serious health problems versus missing problems because of “falsenegative” reports. USING MHEALTH TECHNOLOGIES FOR PATIENT EDUCATION AND SELFMANAGEMENT SUPPORT Mrs. Miller is a 48yearold single mom who rarely attends her appointments. She has never followed through with referrals for diabetes education. As a participant in a program that uses an automated texting system she reports that she is drinking cranberry juice and sodas daily. She is not aware that this makes her diabetes control more difficult. After receiving tailored health education messages from the system, and a reinforcing phone discussion with the nurse about the importance of trying to avoid sugary foods and drinks, Mrs. Miller makes a behavioral action plan and begins diluting her juice with water, and drinking diet soda. Her diabetes control improves. Patients with chronic illnesses require enormous amounts of health information that change with the disease course. Unfortunately, providers infrequently engage in the types of communication behaviors that are associated with greater patient retention and understanding,45 and many are unaware of their patients’ selfmanagement goals.10 When patients face language barriers or health literacy deficits, many lack even rudimentary information about their disease or its selfcare.46 mHealth can provide patients with the information they need at a time when they are best able to assimilate it. Unlike written patient education material, mHealth resources such as those provided via the web can be multimodal (i.e., including graphics, video, and audio) and provide information at a pace that is comfortable for users.47 Importantly, the information provided by mHealth can be tailored to patients’ unique sociodemographic, clinical, and psychological characteristics; and studies show that such tailoring can be important in prompting behavior changes.48 For example, patients with diabetes are interested in receiving health education via mHealth,49 and nonEnglish speakers treated in public clinics may be especially interested in accessing IVR health education with practical information or inspiring messages about selfmanagement, such as how to cope with medication sideeffects and how to cook healthy meals.50 Patients with diabetes from a safetynet clinic who received weekly IVR messages over a 9 month period also reported significant improvement in their selfmanagement behaviors and functional status, as well as greater improvements in these outcomes when compared with patients who attended monthly group medical visits and usual care.51 Most patients remember only a small proportion of the educational messages provided during typical outpatient encounters.52 Given that many patients spend a significant amount of time waiting to be seen by clinicians, safetynet health systems should consider making interactive kiosks available within outpatient settings,53 which can provide selfguided educational content about a wide variety of health topics through a standalone computer. Recent research has demonstrated that kiosks can be a viable education tool in safetynet clinics, pharmacies, and community centers. One study reported as many as 600 uses per month, with the most viewed modules for recipes and meal planning.54 Another similar study found that kiosks in community settings with personalized information about selfcare management could improve selfreported diet and physical activity among Latino patients.55 Additional research has explored the use of embodied conversational agents or avatars to deliver health education and promotion content, delivered either through clinic kiosks or on tablets that can also be accessed at home. This conversational agent technology may better capture aspects of in person communication by using dynamic verbal and nonverbal conversational behaviors, and it has been shown to be an effective way to communicate with patients with limited health literacy.56 It has been shown that this approach could also increase physical activity among older adults in the short term.57 Models for computerassisted selfmanagement education are available,58 and research shows that they can assist patients in identifying self management goals and barriers, and ultimately improving their selfcare. In the context of busy primary care practices,59 such services can address patients’ need for selfmanagement education without adding tasks to the schedules of primary care providers. Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John 5D./ 18 USING Piette MHEALTH TECHNOLOGIES TO FACILITATE INFORMAL PEER SUPPORT ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Safetynet health systems are often poorly positioned to address patients’ need for assistance in coping emotionally with their illness, and mental communicate with patients with limited health literacy.56 It has been shown that this approach could also increase physical activity among older adults Mount Saint Vincent College in the short term.57 Access Provided by: Models for computerassisted selfmanagement education are available,58 and research shows that they can assist patients in identifying self management goals and barriers, and ultimately improving their selfcare. In the context of busy primary care practices,59 such services can address patients’ need for selfmanagement education without adding tasks to the schedules of primary care providers. USING MHEALTH TECHNOLOGIES TO FACILITATE INFORMAL PEER SUPPORT Safetynet health systems are often poorly positioned to address patients’ need for assistance in coping emotionally with their illness, and mental health insurance benefits are typically inadequate to meet patients’ need for counseling. Chronic illness can present an enormous emotional drain on patients. Depression is common among patients with diseases such as diabetes and heart failure,60,61 and patients with comorbid psychiatric problems often have worse outcomes62,63 and increased rates of service use. Many socioeconomically vulnerable patients lack effective social support, and low social support is a risk factor for poor selfcare and increased morbidity and mortality.64,65 Patients who provide peer support to others with the same health condition may address some of these challenges. Patients who provide support to others may achieve health benefits themselves; for example, less depression,66 heightened selfesteem and selfefficacy,67 improved quality of life (even after adjusting for potential confounders),68 improved health behaviors,69 decreased mortality risk,70,71 and improved health outcomes and function.72,73 Peer support can be especially effective in reducing problematic health behaviors74,75 and mental health symptoms.76 Most models of providing chronic disease peer support require patients to attend frequent facetoface visits; most patients who might benefit do not attend, and those who do often drop out after a few encounters. Unfortunately, studies evaluating mHealthfacilitated opportunities for peer support have shown mixed results.77,78 For example, online social networks in Korea were found to increase social support among participants, and this in turn increased patient empowerment and active communication with providers.79 A longitudinal study of a peerled online pain selfmanagement program in England found decreased symptoms and improved health behaviors and selfefficacy.80 Existing public social networks for patients with diabetes, such as those hosted by professional associations, have also been evaluated, with a high amount of variability in the quality of the information provided and the protection of the privacy of participants.81,82 Importantly, mHealthfacilitated informal support services are feasible; however, there is currently little evidence for or against these interventions’ impact on patients’ selfmanagement or health outcomes. Common Pitfalls in Using Interactive Health Technologies Poorly supported mHealth programs can lead to increased resource use devoted to clinically insignificant problems. mHealth services are less effective when they are overly complicated and therefore address multiple issues only superficially. Programs that include a smaller number of welldesigned functions, such as reminders, monitoring, and the provision of selfmanagement education, may be more effective. Not all patients benefit from mHealth interventions. Some do not need additional support and/or training; others such as those with unstable residence or cognitive impairment may not be successfully targeted by generic programs. To be effective for marginalized patients, such as the homeless or severely mentally ill, mHealth requires special adaptations and personalized professional interpersonal support. Developing an mHealth program without active usability testing by end users (both patients and providers) is unlikely to work. mHealth systems that do not involve interactions with clinicians and are not integrated into primary care have limited benefit and actually may lead to confusion. mHealth programs are an adjunct, not a replacement or alternative, to personalized care. THE CHARACTERISTICS OF PATIENTS WHO CAN BENEFIT FROM mHEALTH TECHNOLOGIES Patients with a variety of sociodemographic and clinical characteristics, including those with limited functional health literacy or English proficiency,49 can and will use mHealth as part of their usual outpatient care. In fact, among patients with poorly controlled diabetes, those with limited functional health literacy or English proficiency were more likely than those with adequate health literacy and English speakers to engage with the system (Figure 171). Consequently, if designed with the endusers in mind, IVR and other mHealth systems may have the greatest uptake among patients with communication barriers who often are highly motivated to engage with systems that increase their access to care. Depending on communication channel through which the mHealth program is delivered (e.g., automated phone calls vs. texting), age and technical skills may also influence patient Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Page Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies Vulnerable Populations, Courtney R. Lyles; Dean John 6D./ 18 83 engagement and use. In future work, offering the same content throughfor multiple channels may increase the accessibility of theSchillinger; mHealth program, Piette and training and Hill. support for certain patient Terms subgroups may increasePolicy program uptake and ongoing engagement. ©2024 McGraw All Rights Reserved. of Use Privacy Notice Accessibility Figure 171. Patients with a variety of sociodemographic and clinical characteristics, including those with limited functional health literacy or English proficiency,49 Mount Saint Vincent College can and will use mHealth as part of their usual outpatient care. In fact, among patients with poorly controlled diabetes, those with limited functional Access Provided by: health literacy or English proficiency were more likely than those with adequate health literacy and English speakers to engage with the system (Figure 171). Consequently, if designed with the endusers in mind, IVR and other mHealth systems may have the greatest uptake among patients with communication barriers who often are highly motivated to engage with systems that increase their access to care. Depending on communication channel through which the mHealth program is delivered (e.g., automated phone calls vs. texting), age and technical skills may also influence patient engagement and use.83 In future work, offering the same content through multiple channels may increase the accessibility of the mHealth program, and training and support for certain patient subgroups may increase program uptake and ongoing engagement. Figure 171. The Interactive Voice Response (IVR) System of the IDEALL Project. With extensive input from patients, the authors designed an IVR system sensitive to the literacy and language requirements of the target population. Each week, patients receive a rotating set of questions about diabetes selfcare, psychosocial aspects of diabetes care, as well as receipt of preventive services. Patients who answer out of range on an item (based on predetermined thresholds) receive an immediate automated health education message in the form of a narrative to encourage them to reflect on their selfcare behavior and consider setting goals and developing an action plan around selfcare. Patients who answer out of range also receive a call back from a bilingual nurse care manager to encourage them to set goals and develop an action plan to improve their overall health. The nurse care manager is trained to perform motivational interviewing, assess and overcome barriers to successful diabetes care and health communication, and suggest changes in medical management. Guided by a clinical protocol, the care manager communicates with patients' primary care physicians to implement such changes. The IDEALL Project system is designed in such a way as to promote the efficiency of the nurse care manager by having her only perform those outreach phone calls to patients who, by virtue of their responses to the system, report a need for further support. The IDEALL system requires about 10 minutes to complete per week, and runs for 39 weeks (9 months). The potential benefits of mHealth technologies are unlikely to be equally distributed across patients. Many patients, including some treated in safety net health systems, already have the resources they need to manage their illness effectively. As a result, they may receive little additional benefit from the types of support (e.g., reminders, ongoing monitoring, patient education, and informal support) that are possible through mHealth.84,85 At the opposite extreme, some patients treated by safetynet providers lack the basic necessities that would be essential to take advantage of the support available through mHealth. In particular, patients with serious psychiatric disorders, unstable residences, or inconsistent telephone access may not benefit from the types of services even the most creative mHealth can provide. Safetynet providers should carefully consider which patients could benefit from mHealthbased selfmanagement supports. Often, patients with the poorest health status (e.g., diabetes patients with the worst glycemic control or heart failure patients with repeated acute exacerbations) are targeted for these additional services; however, these may not be the patients who can benefit the most. Rather mHealth may be of greatest benefit to patients who fall between the two extremes of adequate selfmanagement support and intractable social or psychiatric need, that is, the large number of patients who simply need additional reminders, monitoring, selfmanagement information, and other services that they cannot access through usual outpatient sources of care. LINKING INTERACTIVE HEALTH T ECHNOLOGIES WITH USUAL P ROCESSES OF CARE Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Page Chapter 17: Applying Interactive Mobile Healthservices (mHealth) Vulnerable Populations, Courtney R. Lyles; Dean Schillinger; John 7D./ 18 Studies suggest that the outcomes of mHealth are Technologies proportional toforthe extent that they support “live” clinician resources and are integrated Piette with usual processes of outpatient care (Figure 172). When mHealth programs are not linked to clinical responses, improvement in knowledge and ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility perceived social support may occur, but only slight benefit in the more important realms of selfefficacy, health behavior, or health outcomes can be for these additional services; however, these may not be the patients who can benefit the most. Rather mHealth may be of greatest benefit to patients Mount Saint Vincent College who fall between the two extremes of adequate selfmanagement support and intractable social or psychiatric need, that is, the large number of Access Provided by: patients who simply need additional reminders, monitoring, selfmanagement information, and other services that they cannot access through usual outpatient sources of care. LINKING INTERACTIVE HEALTH T ECHNOLOGIES WITH USUAL P ROCESSES OF CARE Studies suggest that the outcomes of mHealth services are proportional to the extent that they support “live” clinician resources and are integrated with usual processes of outpatient care (Figure 172). When mHealth programs are not linked to clinical responses, improvement in knowledge and perceived social support may occur, but only slight benefit in the more important realms of selfefficacy, health behavior, or health outcomes can be demonstrated.86 In addition, mHealth programs that are closely linked with patients’ usual outpatient services are used more consistently over time and may improve important outcomes such as cholesterol levels, symptom burden, and rates of preventable hospitalizations. Furthermore, having a centralized, guidelinedriven system for mHealth that reacts to concerning patient responses—for example, through a nurse care manager—may ensure more consistent and effective treatment plans. Linkages to existing processes are likely important even beyond the clinic level: evidence from successful innovative diabetes programs internationally found that collaboration between academic centers, hospitals, as well as community resources and businesses was a key factor to success.87 Figure 172. Relationship between mHealth linkage to patients' usual clinical care and evidence of intervention effectiveness. mHealth services most closely integrated with patients’ outpatient primary care can improve behavioral and health outcomes. For example, rigorous randomized trials have investigated clinicbased behavioral assessments delivered via a multimedia kiosk in order to identify barriers to self management and structure behavioral interactions between patients and their clinicians.58,85 Such systems have shown consistent, lasting impacts on difficulttochange behaviors (e.g., diet) as well as physiologic outcomes (e.g., cholesterol levels). In addition, several randomized trials have demonstrated that IVR assessment with rapid followup by a telephone nurse care manager can improve outcomes for patients with diabetes or hypertension84,88,89,90,91 or improve survival among patients with advanced congestive heart failure.77 “STANDALONE” INTERACTIVE HEALTH T ECHNOLOGY INTERVENTIONS In general, interventions designed to operate as standalone services (i.e., interventions that are completely automated, with no followup by clinicians) may be seen by patients as superfluous and be used with decreasing frequency over time.92 For example, Pinto and colleagues developed a callin IVR program to assist patients with increasing their physical activity levels.89 Although the recorded messages were tailored and based on sound health behavior change theory, the investigators found that as many as one in four study participants never called the tollfree number to receive behavior change messages, and fewer than half were using the system after 3 months. Not surprisingly, the intervention had no significant impact on patients’ behavior. Incomplete linkages to clinicians or provider care teams may produce modest health improvements. In randomized trials in which patients were connected to an “ecounselor” for weight management (not directly connected to existing primary care teams), investigators found some improvements in weight loss and engagement with the webbased s ystem.93,94 However, all patients regardless of intervention arm significantly decreased their logins to the website over time—highlighting the need for even greater linkages to ongoing care to maximize patient engagement. HOW SHOULD SAFETYNET P ROVIDERS DELIVER INTERACTIVE HEALTH T ECHNOLOGY SERVICES? Numerous private companies produce generic versions of the hardware and software required for implementing mHealth services within a safetynet health system. Other companies are clinical service providers and offer mHealthsupported care management services by charging health systems on a perpatientpermonth basis or other capitated model. The choice of whether to provide mHealth services “inhouse” or through a contracted service agency is important, and 9:30 both A options their advantages. Downloaded 2024218 Your have IP is 63.247.225.21 Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John 8D./ 18 Piette INHOUSE MHEALTH DELIVERY ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility One advantage of inhouse mHealth delivery is that the healthcare organization can have more control over the intervention process and content. For SERVICES? Mount Saint Vincent College Access Provided by: Numerous private companies produce generic versions of the hardware and software required for implementing mHealth services within a safetynet health system. Other companies are clinical service providers and offer mHealthsupported care management services by charging health systems on a perpatientpermonth basis or other capitated model. The choice of whether to provide mHealth services “inhouse” or through a contracted service agency is important, and both options have their advantages. INHOUSE MHEALTH DELIVERY One advantage of inhouse mHealth delivery is that the healthcare organization can have more control over the intervention process and content. For example, inhouse mHealth services can provide greater opportunity to modify the patient messages, integrate systems with electronic health records, or design and change clinician reports. One issue to explore when considering outsourced mHealth supports is that making changes in patients’ communication protocol could be more difficult and costly because of distance barriers and the company’s financial incentives. A disadvantage of inhouse mHealth service development and delivery is that the responsibility for managing the technical aspects of the system falls on the healthcare organization. Most mHealth systems require the use of specialized programming languages and equipment; health systems need to consider whether they have the resources to fund this infrastructure over time. Although it is not clear whether inhouse or subcontracted mHealth is less costly in the long term, equipment purchase for inhouse mHealth may represent a significant initial investment, whereas subcontracted costs can be more constant and predictable. SUBCONTRACTED MHEALTH SERVICES An important issue to address when using subcontracted mHealth services is that these services may complicate care coordination, especially if the vendor includes its own health educators and other health personnel who provide followup when a patient problem is identified. Those clinicians often do not have access to patients’ complete medical records and could make inappropriate changes to treatment plans if clear lines of communication are not established. Without clear protocols for information exchange, even appropriate advice or medication adjustments by outside staff may not be communicated to patients’ primary care team or documented in patients’ charts. Because many patients receive care from multiple providers, clear and consistent lines of communication between mHealth services and others involved in patients’ care are critical so that patients do not become confused as to where they should turn for help when they have a clinical or technical problem using the mHealth system. EVALUATING INTERACTIVE HEALTH TECHNOLOGIES mHealth can improve the disease management and health outcomes for patients treated by safetynet providers, assuming careful thought is given to the intervention’s functioning, the patients, and clinicians it is designed to serve, and how it relates to other aspects of patients’ care. Evaluations of new mHealth services should reflect the intervention’s goals. For example, an intervention designed to increase rates of ophthalmologic examinations among patients with diabetes may not save an organization’s money in the short term, and decision makers should be clear about desired evaluation criteria up front. As described in previous sections, mHealth interventions can play multiple roles in chronic illness care; it may be difficult to implement an intervention that addresses both the goal of cost containment and of increasing use of guidelinerecommended services simultaneously. Priorities should be set to select the optimal role of the system in the context of other available services. If the mHealth solution was not designed or tested with input from vulnerable patients in the context of their everyday life, then it is more likely to be underutilized or ineffective. Usercentered design principles can be particularly useful in creating mHealth technologies for vulnerable patients, such as observational “thinkaloud” interviews to systematically document when patients experience barriers or questions when interacting with early versions of the system.5,95 However, it is often the case that healthcare systems serving vulnerable patients attempt to adapt an existing technology that was originally implemented with a different patient population. Taking the time to pilot an mHealth system with a diverse patient population and adapt it in an iterative manner can greatly improve the functionality and accessibility of the technology as well as the subsequent implementation of the program within realworld practices. Once broader implementation is underway, the traditional gold standard for determining the potential benefits of novel services such as mHealth has been evaluation within the context of a tightly controlled randomized trial. However, many services that have proved efficacious in a research context have shown disappointing results in more “realworld” settings or have not been translated into services that can benefit patients in typical outpatient practices. Consequently, policy makers and clinicians have begun to conceptualize evaluation more broadly than randomized trials. Pragmatic trials have been introduced to aid with the translation of findings into realworld practice—that is determining how programs work under usual conditions present in healthcare settings, rather than ideal conditions within a more tightly controlled clinical trial—which is particularly relevant for understanding how to adapt mHealth programs for safetynet settings.96 The REAIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) framework is one tool for evaluating mHealth implementation in diverse Downloaded 2024218 9:30 A Your IP is 63.247.225.21 practice This Interactive framework Mobile suggests that these services (particularlyforclinicbased educational systems IVR) may be useful Page 9D./ 18 Chapter settings. 17: Applying Health (mHealth) Technologies Vulnerablemultimedia Populations, Courtney R. Lyles;and Dean Schillinger; Johndespite Piette only modest impacts on patient outcomes, because of their low marginal cost, ease of use, and ready availability to patients facing access barriers.97 ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Safetynet providers may find that mHealth can benefit their patients by using perspectives such as that provided by REAIM. This framework is particularly important when adapting technology solutions from other settings to safetynet systems, as both the initial adoption and sustained use of practices. Consequently, policy makers and clinicians have begun to conceptualize evaluation more broadly than randomized trials. Pragmatic trials Mount Saint Vincent College have been introduced to aid with the translation of findings into realworld practice—that is determining how programs work under usual conditions Access Provided by: present in healthcare settings, rather than ideal conditions within a more tightly controlled clinical trial—which is particularly relevant for understanding how to adapt mHealth programs for safetynet settings.96 The REAIM (Reach, Efficacy, Adoption, Implementation, and Maintenance) framework is one tool for evaluating mHealth implementation in diverse practice settings. This framework suggests that these services (particularly clinicbased multimedia educational systems and IVR) may be useful despite only modest impacts on patient outcomes, because of their low marginal cost, ease of use, and ready availability to patients facing access barriers.97 Safetynet providers may find that mHealth can benefit their patients by using perspectives such as that provided by REAIM. This framework is particularly important when adapting technology solutions from other settings to safetynet systems, as both the initial adoption and sustained use of the mHealth solution may look different depending on the patient and system characteristics. CONCLUSION New mHealth services are constantly being developed in parallel with new technology devices that expand communication for all patient populations. The introduction of health information technology in safetynet healthcare settings is also expanding quickly because of health reform and the widespread introduction of patient portal systems. As traditional healthcare resources evolve, mHealth may be able to fill the gaps that arise in care within safetynet health systems that result from the imbalance between the needs of patient populations and the fixed capacity/supply of providers. With careful attention to how mHealth services address longstanding clinical challenges, these tools may alleviate some of the stresses on safetynet clinicians, especially if technology can provide the selfmanagement support for patients between outpatient visits that is crucial but often impossible to deliver through traditional practice models. KEY CONCEPTS mHealth can serve four goals in chronic illness care: —Assisting patients with administrative tasks such as remembering to attend upcoming appointments. —Providing ongoing monitoring of patients’ symptoms, physiologic values, or health behaviors. —Delivering patient education and supporting selfmanagement by providing personalized health behavior feedback. —Facilitating communication with other patients or social network members that can provide informal support. Before implementing a new mHealth program, it is important to carefully consider the program’s goals and target users. Interactive voice response (IVR) systems are simple and inexpensive tools, with substantial evidence for effectiveness and should be considered for use by safetynet providers. If carefully designed with input from end users, mHealth technologies have great potential to improve vulnerable patients’ access to care, health information, and social support. Patients can provide reliable clinical information via mHealth between outpatient encounters. Interactive educational kiosks used in outpatient settings can assist patients in selfmanagement and behavior change efforts. mHealthfacilitated informal (peer) support services are feasible, but their impact on patients’ selfmanagement or health outcomes has not been demonstrated. mHealth is most effective when closely linked with usual outpatient care. Text messaging interventions can be effective for improving health behaviors such as appointment attendance, medication reminders, and smoking cessation. While smartphone applications hold great promise, no studies have shown that they can improve outcomes in vulnerable populations; access to smartphones with reliable data plans is far from universal in lowincome communities. CORE COMPETENCY Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Chapter 17: Applying Interactive Mobile Health Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John10D./ 18 mHealth: Assessing Your Practice Setting and (mHealth) Clinical Challenges Piette COULDMcGraw AN MHEALTH HELP YOUR PATIENTS SELFMANAGEMENT GOALS AND AVOID COMPLICATIONS OF THEIR CHRONIC ©2024 Hill. AllTECHNOLOGY Rights Reserved. Terms of Use ACHIEVE Privacy Policy Notice Accessibility DISEASE? Mountpopulations; Saint Vincent College While smartphone applications hold great promise, no studies have shown that they can improve outcomes in vulnerable access to smartphones with reliable data plans is far from universal in lowincome communities. Access Provided by: CORE COMPETENCY mHealth: Assessing Your Practice Setting and Clinical Challenges COULD AN MHEALTH TECHNOLOGY HELP YOUR PATIENTS ACHIEVE SELFMANAGEMENT GOALS AND AVOID COMPLICATIONS OF THEIR CHRONIC DISEASE? Define a problem that you would like to address. What traditional methods have you employed to address the problem? Why have these approaches failed or only partially succeeded? What types of mHealth technologies do you think might help address the problem? What are clinician attitudes toward integrating mHealth applications? What are the characteristics of patients and which adaptations might your mHealth need to have the greatest reach and effectiveness? REVIEW “OFFTHESHELF” PROGRAMS Will they work for your setting and your patients? Have they been tested for usability in a similar patient population? Can you adapt them to suit your needs? Do they allow for integration with clinic personnel and workflow? What would be the purchase cost overall and per patient served? What would be the impact on the costs of other services your organization provides (e.g., followup calls to address problems identified via the mHealth service)? Do you have resources and staff to support the mHealth or develop and implement your own? DISCUSSION QUESTIONS 1. mHealth services (e.g., regular IVR assessment calls) may identify important health or selfmanagement problems between outpatient visits. However, such systems also may provide ambiguous clinical data that require additional followup by clinicians. Given that most safetynet health systems are already burdened with pressing patient care problems, what are the benefits and costs of “trolling” for additional problems via mHealth? For what types of patients and health problems may mHealth monitoring be most useful? 2. Given the widespread implementation of online patient portals, what do you think are the greatest challenges for use among (1) vulnerable patients and (2) providers in safetynet systems? How do you think the initial challenges with adoption will differ from longer term engagement/use? 3. Should public health systems develop web or textingbased educational supports for their patients, even though not all patients could use them? How should clinicians and administrators assess such services, so that scarce resources are used effectively without investing excessive time and money in evaluating intervention effects? 4. Clinicians need accurate and timely information to make decisions, but mHealth can add additional data (e.g., guidelines, clinician reminders, patient functional status information) to the process of care. How much information is too much? How should clinicians and health systems decide what mHealth information is helpful in patient care and what is simply a distraction? 5. Should safetynet health systems develop the infrastructure for delivering mHealth services “inhouse” or contract such services with an outside vendor? RESOURCES Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies forhttp://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406758 Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John11D./ 18 For information on health information technology in the United States, see Piette ©2024 McGrawon Hill. All RightsmHealth Reserved. Terms of Useframework, Privacy Policy Notice Accessibility For information evaluating within the REAIM see http://www.reaim.hnfe.vt.edu/ patient functional status information) to the process of care. How much information is too much? How should clinicians and health systems decide what mHealth information is helpful in patient care and what is simply a distraction? Mount Saint Vincent College Access Provided by: 5. Should safetynet health systems develop the infrastructure for delivering mHealth services “inhouse” or contract such services with an outside vendor? RESOURCES For information on health information technology in the United States, see http://www.rwjf.org/content/dam/farm/reports/reports/2013/rwjf406758 For information on evaluating mHealth within the REAIM framework, see http://www.reaim.hnfe.vt.edu/ For information regarding the IDEALL Project at San Francisco General Hospital, see http://www.commonwealthfund.org/publications/tools/2004/jun/betterdiabetescareforpatientswithlowhealthliteracy For information on the use of telephone care in chronic disease management, see http://www.chcf.org/publications/2005/06/usingtelephone supporttomanagechronicdisease For more information on patient portals and Meaningful Use financial incentives, see http://www.healthit.gov/providersprofessionals/faqs/what patientportal http://www.cms.gov/RegulationsandGuidance/Legislation/EHRIncentivePrograms/Meaningful_Use.html REFERENCES 1. Zickuhr K, Smith A. Digital differences: PewResearch Internet Project; April 13, 2012. 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[PubMed: 15275676] ACKNOWLEDGMENT Dr. Piette received additional support from NIH grant no. P30DK092926. Dr. Lyles received support from AHRQ grant no. R00HS022408, and Dr. Schillinger received support NIH grant no. P30DK092924. Downloaded 2024218 9:30from A Your IP is 63.247.225.21 Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John17D./ 18 Piette ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility Mount Saint Vincent College ACKNOWLEDGMENT Access Provided by: Dr. Piette received additional support from NIH grant no. P30DK092926. Dr. Lyles received support from AHRQ grant no. R00HS022408, and Dr. Schillinger received support from NIH grant no. P30DK092924. Downloaded 2024218 9:30 A Your IP is 63.247.225.21 Chapter 17: Applying Interactive Mobile Health (mHealth) Technologies for Vulnerable Populations, Courtney R. Lyles; Dean Schillinger;Page John18D./ 18 Piette ©2024 McGraw Hill. All Rights Reserved. Terms of Use Privacy Policy Notice Accessibility

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