2 stanford talkdyer

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Jennifer Shine Dyer M.D., M.P.HJennifer Shine Dyer M.D., M.P.H..Chief Medical AdvisorChief Medical Advisor

eProximitieProximitiDuethealth.comDuethealth.comColumbus, OhioColumbus, Ohio

May 2011May 2011

'What Really Works': Diabetes and 'What Really Works': Diabetes and Mobile Health in Medical PracticeMobile Health in Medical Practice

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What Really Works?...What Really Works?...

• Asking a patient: ‘What Really Isn’t Working?’

• Solid Doctor-Patient Relationship

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What Really Isn’t Working?What Really Isn’t Working?

• Skipping boluses

• Reduced mindfulness

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BasalBasal InsulinInsulin

Prandial Boluses

Insu

lin

0hr 24hr

BG

mg

/dl

Intensive Basal Bolus TherapyIntensive Basal Bolus Therapy

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Meal BolusMeal Bolus

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Pump download, missed meal bolusesPump download, missed meal boluses

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Solid Doctor-Patient RelationshipSolid Doctor-Patient Relationship

• Frequency of communication (email, phone recorded by EMR encounters)

• Frequency of clinic visits

• Press Ganey scores

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HypothesisHypothesis

• Weekly personalized and interactive engagement via texting with the physician will improve meal bolus mindfulness and reduce hgba1c % within 3 months (at next clinic visit) in teens with type 1 diabetes.

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SubjectsSubjects

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MethodsMethods

Weekly Texting Protocol (Thursdays at 5pm)Weekly Texting Protocol (Thursdays at 5pm)• Initial greeting message• Customized question unique to each patient’s

interests• Questions specific to adherence• Conclusion message

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ResultsResults

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What Really Isn’t Working?What Really Isn’t Working?

• Bolus adherence and glucose checks decreased over time

• Needed motivation

• Needed reminders

• Needed more support

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eproximiti.com duethealth.com

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Phone, tablet, and iPod touch versions available for both platforms.

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Duet Duet

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Duet Pilot DataDuet Pilot Data

Group Group

• 3 OBGYN Doctors

• 30 Days, asked 60 patients – 100+

participated

ResultsResults

• Feb-March 2011

• Doctors handed out all materials in 7 days

• By 10th day, 20% of patients opened app more than 9 times

PhysicianPhysician FeedbackFeedback

• Andrew Bokor, MD (OB/Gyn):

”I don’t think there is any way it won’t

improve quality of women’s health

care and outcomes”

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What Really Isn’t Working?What Really Isn’t Working?

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BJ Fogg’s Health Behavior ModelBJ Fogg’s Health Behavior Model

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Motivating & Rewarding BehaviorMotivating & Rewarding Behavior

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Motivating & Rewarding BehaviorMotivating & Rewarding Behavior

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Motivation from SupportItunes points

Social Network supportPositive reinforcement from friends & family. Motivation + rewards.

Using Peer & Family ReinforcementUsing Peer & Family Reinforcement

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Doctor-Patient Communication, Education, and Literacy Data Mgmt

Weekly Texting Reminders

Comprehensive Patient ToolsComprehensive Patient Tools

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Hypothesis: Teens that open app daily over 3 months will check glucoses more and improve meal bolus adherence

Primary outcome variable: ∆ hgba1c% change∆ hgba1c% change over 3 monthsbetween control and intervention group

Study Enrollment

Control Group: Control Group: Standard of care

routine office contacts

Intervention Intervention Group: Group: Weekly

personalized automated texts

Routine Office Visit (3 months)

•Routine hgba1c %•Psychology exit survey

•Routine hgba1c %•Psychology intake survey

Real-time conversation monitoring for safety

•All contacts recorded (both texting and routine office contacts)

50 patients

50 patients

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What Really Works?...What Really Works?...

• Mobile tools that focus on what really matters in healthcare:

-solving problems

-compassion

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Jennifer Shine Dyer MD, MPHChief Medical Advisor

[email protected]@gmail.com

eproximiti.com duethealth.com

© 2011 eProximiti, Inc. All rights reserved

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Dyer Health Care Social MediaDyer Health Care Social Media

• Blogging• Podcasts• Twitter• Facebook• Linkedin• Youtube• Health Literacy: Online Content• mHealth

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BloggingBlogging

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TwitterTwitter

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FacebookFacebook

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LinkedInLinkedIn

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YouTube YouTube

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PodcastPodcast

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Health Literacy: Online ContentHealth Literacy: Online Content

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mHealth: app developmentmHealth: app development

• Automated SMS texting• Personalized features• Bolus reminder system

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The United States of Diabetes?The United States of Diabetes?

Half the Country Could Have Diabetes or Prediabetes by 2020Predicted cost of $3.35 trillion (10% of total healthcare spending)

The United States of Diabetes: Challenges and Opportunities in the Decade Ahead, UnitedHealth Group’s (NYSE: UNH) Center for Health Reform & Modernization, November 23, 2010: http://www.unitedhealthgroup.com/newsroom/news.aspx?id=36df663f-f24d-443f-9250-9dfdc97cedc5

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External Internet Services: Facilitate initial programming, Facilitate operations ofExternal Internet Services: Facilitate initial programming, Facilitate operations ofSMS texting delivery and storageSMS texting delivery and storage

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Nick

Jonas

Music

Also loves Frappuccinos.

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Hey Nick! I’ve added you to my address book!

Cool. Thanks! Keep rockin’ Dr. Dyer.

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Dr. Dyer here. Hope the work on the new album is going well. Can’t wait to hear a sample on your next visit! February 10th

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Hey Nick. How is it going with your boluses? February 17th

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Nick. Hope the carb counting is going well. I know u love Frappuccinos! :) February 24th

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Keep on rocking the boluses, Nick! See you in a few weeks. March 3rd

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Conversation Monitoring: Tweetdeck InterfaceConversation Monitoring: Tweetdeck Interface

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Hypothesis: Teens that receive weekly personalized automated texts over 3 months will have a significant drop in hgba1c%

Primary outcome variable: ∆ hgba1c% change∆ hgba1c% change over 3 monthsbetween control and intervention group

Study Enrollment

Control Group: Control Group: Standard of care

routine office contacts

Intervention Intervention Group: Group: Weekly

personalized automated texts

Routine Office Visit (3 months)

•Routine hgba1c %•Psychology exit survey

•Routine hgba1c %•Psychology intake survey

Weekly conversation monitoring on Dyer iphone

for safety

•All contacts recorded (both texting and routine office contacts)

50 patients

50 patients

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TriggerTrigger

Make the mobile phone DO SOMETHING at the right time:

• Send push notifications

• Add calendar events with alarms

• SMS

• CALL

• (Email)

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MotivateMotivate

Make the patient WANT to take their medication:

• Utilize Game MechanicsImagine piloting a nanobot through the bodies of fictional cancer patients, destroying

cancer cells in your path, battling bacterial infections, and managing side effects. This is the Re-Mission game, developed for adolescents and young people with cancer, that hopelab.org believe will help them develop a positive attitude, learn about their cancer and has been shown to improve adherence. – Roberts

• Competition

• Social

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Data ManagementData Management

• September 21, 2010

• Sanofi Aventis iPhone/iPod-linked blood glucose meter iBGStar and free management app

• To be submitted to FDA in near future

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Cost Benefit AnalysisCost Benefit Analysis

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• Nationwide Children’s Hospital, 7 physicians

• Academic year (6/1/08-5/31/09)

• 1,425 different patients with type 1 & type 2 diabetes

• 4,057 diabetes outpatient clinic visits

• Average of 200 diabetic patients per physician

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• ~175 inpatient admissions for DKA (involving ~70 different patients)

• ~80% related to nonadherence

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• 140 inpatient admissions for DKA related to nonadherence

• Average diabetes 3-5 day admission for DKA costs ~$10,000

• Total costs of $1.4 million per Total costs of $1.4 million per yearyear

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• Reimbursement for texting overhead:Reimbursement for texting overhead:- 3 cents per text- 7 texts per patient per week- 21 cents/patient/week- $42 per week per physician taking care of average 200 diabetic patients-~$11 per patient per year-~$11 per patient per year

• Reimbursement forReimbursement for physician timephysician time per week spent on texting:- 5% of clinical activity- 5% of salary - $10,000 per year- $200 per week- $1 per patient per week$1 per patient per week to physician taking care of average 200 diabetic patients for each texting encounter

• Total reimbursementTotal reimbursement (overhead + time): - ~$65 to physician per patient per year- ~$65 to physician per patient per year

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• Potential savings:Potential savings:

+$1.4 million per year+$1.4 million per year

• Reimbursement costs for 70 Reimbursement costs for 70 different patients: different patients:

-$4,550 per year-$4,550 per year

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In Conclusion…In Conclusion…

Challenges remain:

• Privacy

• Insurance reimbursement incentives

• Medicine is slow to change

…but we’ve come a long way, anything (even mHealth) is possible!

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1922: PioneerThe police in Chicago experiment with a radio telephone which broadcast at a frequency just above the AM radio

band.

http://www.time.com/time/photogallery/0,29307,1636836_1389493,00.html#ixzz15BlbmzVi

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1940s: HorsebackThe US Army Signal Corps communicate via radio in the field during wartime.

http://www.time.com/time/photogallery/0,29307,1636836_1389499,00.html#ixzz15Bm7vMUI

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1959: Commercial ModelReginald Blevins, the Postmaster General of the UK, inaugurates the first radio

telephone service for motorists.

http://www.time.com/time/photogallery/0,29307,1636836_1389495,00.html#ixzz15BmJ5SQn

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1972: PortableA model shows off a unit that could dial into telephone systems, displayed at a London exhibition entitled,

"Communications Today, Tomorrow and the Future."

http://www.time.com/time/photogallery/0,29307,1636836_1389496,00.html#ixzz15BmSawMk

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1981: Portable Units• The first portable units were

really big and heavy.

• Called transportables or luggables.

• They were so large mainly because of the size of the battery that they were housed in their own briefcase.

Source: http://www.galaxyphones.co.uk/mobile_phones_history09.asp

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1983: InventorMartin Cooper is credited with developing the first cell phone approved for

commercial use.

http://www.time.com/time/photogallery/0,29307,1636836_1389497,00.html#ixzz15BmcHsNI

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1983: DynaTAC 8000X

• In 1983 Motorola released the first true mobile phone.

• It weighed about the same as a bag of sugar and had a battery life of only 8 hours

• It cost $3,995 and sold over 300,000 units in the first year alone.

Source: http://www.i4u.com/article421.html

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1988: In the FieldFrenchman Frank Piccard calls in after taking Gold in the Super G at the 1988 Winter

Olympics.

http://www.time.com/time/photogallery/0,29307,1636836_1389498,00.html#ixzz15BnJuNUs

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1989: GSM Digital Phones

• In 1989 digital networks lead to the increased use of mobile phones throughout the 90’s.

• The vast majority of phones were black or dark grey with aerials and small screens.

Source: http://www.motorola.com

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1993: Simon Smartphone

• First smartphone

• It was created by IBM in

1992 and sold in the US from 1993.

• It was a mobile phone, basic computer, pager and fax machine.

• Cost was $899

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1996: Mobile Internet Connection

• The first popular smartphone was the Nokia Communicator, released in 1996.

• The phone looked like a normal (but very big) phone on the outside but opened to reveal a full QWERTY keyboard.

• The Communicator was able to connect to the Internet (VERY slowly...)

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2002: BlackBerry

• The original Blackberry had a monochrome (black and white) screen and was used for email, surfing the Internet, fax and phone services

• BlackBerry is manufactured by a Canadian company – RIM (Research in Motion)

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Evolution of the Blackberry

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2006: Camera PhonesPalestinian students at a Ramallah University photograph physicist Steven Hawking,

who has arrived to give a lecture.

http://www.time.com/time/photogallery/0,29307,1636836_1389508,00.html#ixzz15BoNhxy4

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2007: Text is NextMorgan Pozgar, 13, of Claysburgh, Pennsylvania, competes in the LG National

Texting Championship at the Roseland Ballroom in New York.

http://www.time.com/time/photogallery/0,29307,1636836_1389509,00.html#ixzz15BoeYHNS

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2008: BlackBerryIn the last election, Barack Obama used his BlackBerry to arrange his appointments, surf

the internet, and keep in touch with his team while he was on the road.

http://www.thetechherald.com/article.php/200908/2972/Mitnick-Obama-s-BlackBerry-can-be-breached

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http://www.time.com/time/photogallery/0,29307,1636836_1721987,00.html#ixzz15BoqFZg8

2008: The iPhone 3GSteve Jobs unveils the latest generation of his revolutionary product. The 3G is faster

and less expensive than its predecessor with larger screen for video.