Interview with Tom Manely Program Manager: UCSF mHealth Technology Group

Tom Manley is the UCSF’s Program Manager for the Mobile Applications Team at the University of San Francisco School of Medicine. As the program manager, he oversees a team that develops mobile applications and mobile health (mHealth) initiatives for UCSF’s School of Medicine. The mHealth Technology Group has released mobile applications targeted for public use on the iPhone. His team also develops a wide variety of service, research, clinical and administrative projects targeting  J2ME, iOS, and Android devices for several UCSF departments.

Topics:

1) Capoison Hotline: a program that text messages poison tips to Californians.

2) PHI: According to Wikipedia, PHI is defined as protected health information. “Protected health information (PHI) is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual. This is interpreted rather broadly and includes any part of a patient’s medical record or payment history.

Under the Health Insurance Portability and Accountability Act (HIPAA), PHI is linked to the following 18 identifiers which must be handled with special care. These 18 identifiers are the following:

1. Names
2. All geographical identifiers smaller than a state
3. Dates (other than year) directly related to an individual
4. Phone numbers
5. Fax numbers
6. Email addresses
7. Social Security numbers
8. Medical record numbers
9. Health insurance beneficiary numbers
10. Account numbers
11. Certificate/license numbers
12. Vehicle identifiers and serial numbers, including license plate numbers;
13. Device identifiers and serial numbers;
14. Web Uniform Resource Locators (URLs)
15. Internet Protocol (IP) address numbers
16. Biometric identifiers, including finger, retinal and voice prints
17. Full face photographic images and any comparable images
18. Any other unique identifying number, characteristic, or code except the unique code assigned by the investigator to code the data

Wikipedia (n.d.) Protected Health Information. Retrieved December 11, 20011, from http://en.wikipedia.org/wiki/Protected_health_information

The main issue that surrounds mHealth programs are telephone numbers. Tom gave an example of a Washington State program that attempted to text flu shot booster reminders to recipients. When the original shot was given patients were asked if they wanted to receive a text reminder for their booster shot. According to Tom, many of the shot recipients were inclined to receive a text message reminder when it was time to receive their booster shot.

The issue: Unfortunately, it sounded like the follow up method wasn’t well thought out. Patients interested in receiving a booster shots needed to provide written consent and opt-in to the service. Since telephone numbers are PHI and treated with special consideration under HIPAA, the text message reminder was limited to the type of information it could include in the message. Reminders were sent to the patients who said yes to the text reminder. However, no information directly tied to the time, place, or diagnosis could be included in the message. Therefore, a very general message that was ineffective was sent to recipients. PHI needs vetting before creating a mHealth text based program in the United States. We found that UCSF researchers required full consent from qualified participants to be included in their SMS based intervention studies. Some of these studies were linking mHealth programming to electronic health records to provide holistic health care services to research participants.  Linking participants personal health records to the text message services allowed researchers to send messages to patients about their primary and secondary health conditions such as hypertension, diabetes, depression, and other possible diagnoses. Additionally, participants in one study at UCSF could text for lab results at anytime. This helped participants monitor their levels and engage in managing their own healthcare.

It’s possible to develop mHealth programs that benefit the public. When designing the program participant consent must be considered in order for the program to have potential success. Sending generic messages that have limited information and can’t be tied to a participant’s illness will devalue the service and intention of building health literacy skills among high needs populations

Just Text Me: Using SMS Technology for Collaborative Patient Mood Charting | Journal of Participatory Medicine

Just Text Me: Using SMS Technology for Collaborative Patient Mood Charting | Journal of Participatory Medicine.

TXT2STOP Trial

Sarika Bansal

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Oct. 7 2011 — 1:29 pm | 0 comments

Can text messages be used to improve health outcomes?

Imagine you are trying to quit smoking. In the process, you receive a text message saying, “This is it! – QUIT DAY, throw away all your fags [cigarettes]. TODAY is the start of being QUIT forever, you can do it!” Would that text message increase the likelihood of you quitting?

Researchers in the UK believe that such text messages may in fact double the likelihood of smokers quitting. The team randomly divided 6,000 smokers into two groups, one that received intervention texts (such as the one above) and another that received texts unrelated to smoking (e.g., “Thanks for taking part!”). They periodically messaged study participants for six months, and at the end of the period, biochemically verified whether or not the participants had stopped smoking.

To the delight of mobile health proponents around the world, the researchers found that nearly 11% of smokers in the intervention group quit smoking, as compared to 5% of those in the control group. They published their findings in the Lancet this summer.

This study is part of a growing trend towards using mobile phones as platforms to encourage healthy behaviors. With over five billion mobile phone connections worldwide, it is not surprising that the public health community is looking to use them to improve health outcomes. Proponents have even created a catchy term, “mHealth,” to encompass all medical practices supported by mobile devices.

“This is the most excited I’ve seen the medical community get for the last ten years,” said Dr. Kevin Clauson, Director of the Center for Consumer Health Informatics Research, where he conducts mHealth research. “Some people think there’s too much hype around mobile health, but I won’t do anything to quell people’s enthusiasm.”

Within mHealth, text messaging seems to offer some inherent advantages. It is relatively cheap (in the US, texts cost 2-10 cents apiece, and unlimited plans make them even cheaper), fairly ubiquitous (most simple analog phones offer texting services), and allows healthcare professionals to connect with users on an ongoing basis. Texts can also be used in a variety of ways. In addition to sending motivational anti-smoking messages, they can be used to remind people to take their medicine, schedule regular doctor appointments, and check for certain abnormalities.

Dr. Thomas Brennan, who researches mobile health applications at the University of Oxford, believes text messaging is especially useful for chronic diseases. “Conditions like hypertension, diabetes, asthma, obesity, smoking – they all have to do with changing individual behavior over time. SMSes are probably the most useful way of engaging with [patients with these conditions].”

As with any technological innovation, however, there are several kinks to be ironed out before healthcare providers start sending text messages en masse. These kinks can be divided into two categories: the operational challenges and the broader business challenges.

From an operational standpoint, there is a very real risk of health text messages eventually being considered spam. Brennan believes this risk is greatest if the messages are not personalized. “If they’re just coming out of the cloud,” Brennan said, “I think they’ll have a limited impact.” To his point, he mentioned the recent creation of an SMS anti-spam system.

To counter this risk, health blogger Andre Blackman thinks health text message systems must operate with an “opt-in” approach and be very transparent with the user. This includes informing people of how often they will receive text messages and giving them an easy way to opt out if they wish.

Another operational consideration is the look and feel of the texting systems. Researchers hypothesize that text message systems work better if they are interactive rather than one-way – meaning that users should be able to ask questions and receive more targeted health information if desired. To that end, Dr. Clauson’s team is currently conducting a study to monitor the differences in diabetes outcomes with uni-directional and bi-directional texting.

http://blogs.forbes.com/sarikabansal/

Text4baby Shows Promising Results for Moms | The White House

Text4baby Shows Promising Results for Moms | The White House.

Dr. Judy Moskowitz: USCF Osher Center for Integrative Medicine

My interview today was with Dr. Judy Moskowitz.

Dr. Moskowitz holds a PhD in Social Psychology from Darmouth University and an MPH in Epidemiology from UC Berkeley. She currently holds the role Associate Professor in Residence in the Department of Medicine at UCSF.

Mission of UCSF Osher Center for Integrative Medicine

We offer a dynamic approach to health, healing and prevention by integrating modern medicine with established practices from around the world.

Our mission is to transform the way medicine is practiced by:

• Conducting rigorous research on integrative and complementary healing practices;
• Educating medical students, health professionals and the public about these practices; and
• Creating new integrative models of clinical care that combine modern medicine and established healing practices emphasizing prevention, patient empowerment and whole person healing.

Whether translating science into hope or discovery into care, UCSF is advancing health worldwide through activism, education, scholarship and research. A healthier future requires us to challenge preconceptions and biases about practicing good medicine.

UCSF Osher Center for Integrative Medicine (n.d)  Osher Center for Integrative Medicine Mission. Retrieved October 27, 2011 from http://www.osher.ucsf.edu/about/mission.html.

Research and education focused on CAM (complimentary alternative medicine) Translation of medicine, using complementary healing practices. Educating students, health professionals, etc. OSHER applies a cross cultural,  interdisciplinary, and evidence-based comparative approach to health.

We met with Dr. Moskowitz and her post doc researcher Dr. Laura Saslow. Dr. Saslow is studying the efficacy of SMS based interventions to provide positive messaging to chronically ill patients. The research focuses on a control group that gets 1-1 counseling. The intervention group is getting messages on learning skills to reduce stress through positive thoughts.

A new program being rolled out to UCSF staff will translate an in person stress reduction program using complimentary alternative medicine techniques to a technology based intervention. Laura said that a text message reminder would be phase two of her research. At present, she has put together the messaging from inspirational quotes she found from a number of meditation and Namaste inspired websites. The user will select skills they want to learn and practice to improve their mental health and well being. Based upon those skill, the participant will receive a daily message. For example, if a participant wanted to learn how to meditate, they would be sent messages on how to meditate to build their skills and reinforce their knowledge of how to practice.

Laura spoke to us about Text 4 Baby which is a mobile health information service for expecting and new  mothers. She has culled all their messages and sent them to me along with some book recommendations.

She used Amazon’s Mechanical Turk to upload her messages and test them for best use. She found that this particular service allowed reviewers to rank messages that resonated the most with them. The sampling is considered broad enough to cover attitudes and believes across the country.

Overall, we had a great interview with Dr. Saslow and Dr. Moskowitz. Mental heath is an area that needs focus for critically ill patients’ ability to engage in managing their health. They are looking at ways to deliver positive messaging and support at the point of need.

Joy Graham at SFGH Barnett Briggs Medical Library

SFGH’s Barnett-Briggs Medical Library provides relevant, specific, and accurate health-related information to support the patient care, patient education, clinical education, research, and program development activities at San Francisco General Hospital and Trauma Center.

SFGH Barnett-Briggs. (n.d.) About the Library: Barnett-Briggs Medical Library. Retrieved October 16, 2011, from http://sfghlibrary.ucsf.edu/services/about-the-library

Kathleen and I met Joy Graham at SFGH Barnett-Briggs Medical Library. Joy is the Library Manager. Her library provides services to the county hospital and to the San Francisco Department of Public Health. We spoke about the library’s current mobile or text messaging services.

Barnett-Briggs has a Text-a-Librarian reference service. The service targets nursing staff at General Hospital. Nurses’ text questions to reference librarians by messaging the keyword SFGH to 66746. The service has been successful in providing this user group information at the point of care. The library has established a standard response time based on complexity of the question. Typically, the nurses receive an answer in ten minutes to two hours. The program received a lot of use when it was first rolled out to the user group. The service level has dropped slightly since it was first rolled out. Joy believes that’s due to the ongoing marketing of the service. All library programs and services need a certain level of marketing to keep them running at higher usage levels.

Joy spoke of several initiatives that she sought out grant funding. Some proposals have been granted others didn’t get funded. Currently, she’s engaged with a Mission district based community based organization (CBO)called Caminos on a digital literacy project. Caminos’ mission is to enable low-income Latina immigrants to create self and economic development opportunities through technology.  I checked out their website to see their services. You can browse their organization by clicking on the link. www.caminossf.org.

Using the train the trainer model the library will provide instruction on how to access, evaluate and retrieve health information online. The purpose of the program is to develop both digital and health literacy skills for these women. This model helps users actively engage in learning how to use the resources for their medical conditions and issues to promote better health among this population. Caminos commitment to empowering women to disseminate health information suggests that they can promote healthy outcomes. Community engagement cultivates long lasting relationships. If women can find the information they want at the point of need, they can potentially obtain the appropriate services for themselves and their family members.

Joy’s program is an excellent example of how the library can boundary span and provide innovative services to users who need health information. Health information needs to meet users where they figure comfortable. Partnering with a CBO integrates the tools and access in an environment where the user receives direct services. If the service isn’t readily available, it seems less likely that it will get used. More mobile services and initiatives may spawn from the success of this project. It will be interesting to see the results after the program gets launched.

On another note, Joy provided us the following statistics on SFGH’s population.  8% of their patients are homeless and 33% uninsured. We also discussed mHealth and how its principles tie in nicely with their population. Joy works tirelessly to deliver high quality information services to this diverse population.

Questions that come to mind:

Who else can Barnett-Briggs partner with on digital literacy training?

Do community based organizations know about SFGH’s medical library?

 

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NCD Prevention: The Potential of Women and Mobiles

NCD Prevention: The Potential of Women and Mobiles.

A link to a blog post from Health Unbound. This post focuses on the number of women dying from non-communicable diseases in the developing world. The post underscores the need to empower women with mobile phones to gain access to healthcare. “Improving women’s access to mobile technology in tandem with mobile supported NCD programs may play a role in making the affordable interventions supported by the UN a reality.”

http://www.healthunbound.org/content/ncd-prevention-potential-women-and-mobiles#.TpJ4x_f50lc.wordpress

mHealth for Patients, Caregivers, and Supporters

My curiosity about SMS messaging and its application in delivering healthcare services has grown. Using SMS messaging services to reach patients at the point of need fuels my passion to reduce health disparities in under-served populations. Learning about Dr. Kahn’s research study at SFGH’s Ward 86 validates that mHealth has a domestic application. Our meeting brought up more questions after my last posting. One in person meeting shed an incredible amount of light on how patients can access their personal health information.  New ideas are forming in my head about how to re-purpose health information for patient care. Now that I am gaining a better understanding of eHealth and its application in mHealth. It actually got me thinking about the broader application of mHealth to promote population health for all. I am interested in developing a broader discussion on how mHealth applies to additional populations and their support team.

How about offering SMS messaging services to all patients regardless of socioeconomic status? Our conversation got me thinking about my own health. What about messaging caregivers? I’ll use my self as an example.

I am a healthy woman so far free from any serious or chronic health conditions. I more or less visit my physician on an annual basis for routine check ups. Routine lab work is done at these appointments. I usually receive the results in the mail 7-10 days after my appointment. They have always come back normal. Since my exams have been healthy and routine, I don’t pay much attention to the lab results. As a matter fact, I throw them out. It’s normal. Why bother to keep a document that’s been archived at my physicians’ office. I’d imagine that’s part of my permanent file. However, I don’t know if that’s true or not. The doctor signs off on the results. I know that’s a fact. I’m sure a copy goes into my file.

When I return for my annual check up we go through the routine questions. No change is my answer to 99% of their questions. We repeat the exam and I head to the lab for my tests. I have no recollection of my lab results from the previous year. I simply haven’t paid attention. After speaking to Dr. Kahn, I want access to that data. I go to the doctor for my personal health. I should know my lab results. Better yet I should be able to retrieve my results from the previous year, so that I can monitor any changes that come back. I’d even be interested in knowing if my blood pressure was different from the previous year’s exam. Simple data points I can query to manage my health from a personal health record would be incredibly powerful. I want to empower myself to understand how to formulate better questions when I see my physician.

Dr. Kahn’s research got me thinking about how patients, caregivers, and other supporters can aid in following care instructions after routine check ups or hospitalization.  I tweaked my research question to help me find new data in the literature on my problem.

I am studying SMS messaging services to learn more about the efficacy of chronic disease management in HIV/AIDS impacted women and youth, so that  my readers can better understand how using technology can promote population health.

I am thinking about the following questions as I seek more data for my project:
What are the limitations of SMS messaging services?
How scalable are these programs?
Does it require a universal electronic health record?
How can we make EHR interoperable?
How can we query the database to retrieve universal health records?
How do you authenticate users to access their health records via SMS text messaging?
What post operative instructions can be delivered via SMS messaging?
What about caregivers? Can we text them patient care instructions?
How many messages do we send?
At what interval and for how long?
Who develops the messages?
What role do librarians play in SMS messaging services? How can librarians influence stakeholders to develop these programs? Are librarians looked to as thought leaders in developing these tools for healthcare services? Do researchers, healthcare providers, and community based organizations looking to the library as the resources to promote these services?

I seek to demonstrate how effective mHealth tools can be for all. One last question. Where does mHealth fit into the policy landscape?

Lessons from Dr. Kahn: Positive Care Program| Ward 86| AIDS/HIV clinic at San Francisco General Hospital

I sat down with Dr. Kahn and Kathleen this morning to discuss the application of SMS text messaging for HIV impacted patients. Dr. Kahn conducts research on patients at the Positive Health Program at San Francisco General Hospital (SFGH). Ward 86 is a primary care clinic for patients infected with AIDS/HIV and is one of the oldest in the country. The internationally recognized clinic is the result of a collaborative effort between San Francisco Department of Health and the University of California San Francisco’s Medicine Medical Service.

Ward 86 has a comprehensive care model that includes the following services:

1. Outpatient primary, specialty HIV Care, integration of  patient care and clinical research, and education for patients, providers and local community
2. Access to specialty clinics such as urgent care, sickle cell, diet and nutrition an oncology…
3. Crisis and intervention management, social work services, and referral services

We discussed Dr. Kahn’s SMS texting program for his clinical patients at Ward 86. The population served is 90% male. 44 years old is the median patient age. Dr. Kahn is studying the efficacy of SMS messaging for disease management. His communication strategy sends text messages to patients that manage the following diseases/health conditions: HIV, Drug Use, Diabetes, High Cholesterol, Hypertension,  Depression.

Dr. Kahn spoke about engaging his patients in receiving SMS text messages to manage their diseases. The main barriers patients face in retrieving their electronic patient health information is access to the Internet, literacy and computer competency. Dr. Kahn provided great insight on how important electronic health records are to delivering SMS messages to patients.  His database maps ICD 9 codes to patient messaging. Patients receive messaging based upon the diagnosis that’s queried from their database.

Each disease has a ten messages that have been created for patients to receive. The SMS messaging service is automated. Text messages are set up on timed intervals. Patients that take ART’s at 8am receive a message reminder at the time. Patients also receive notification of new information that’s been added to their electronic health record.

Dr. Kahn has found a mixed level of literacy skills in the population that he studies at Ward 86. Many of his patients have limited or no access to the Internet at home. His patients typically access the Internet at the public library, hospital library or community based organizations. His study connects patients to their electronic health record. The EHR is a free and secure web-based product that he’s developed for his research called HERO.

Although his patients have limited access to the Internet when surveyed. He found that they all had cellular phones. The mobile phone providers varied among the population. He found that the majority used Metro PCS a pay as you go service and less than 50% had a smartphone. All of his study participants can receive basic text message services.

The connection between cellular phone and the Internet based electronic health record is quite intriguing. Dr. Kahn has collaborated with SFPL’s Project Read  to increase literacy and computer competency skills among his patients. Many of his patients have set up an email account for the first time. They are teaching these patients basic skills on how to use the computer and browse webpages for information . Each participant must learn how to find the cursor, cut and paste, scroll down a page, and find a URL. These are pretty basic skills that most of us take for granted.

Dr. Kahn opens up the discussion on how basic skills need to be taught in order interact with electronic information.  Message notifications trigger patients to retrieve new information from the their health record.

Barriers to accessing patient information include:

Language: All messages are currently in English. Translating them into Spanish and Chinese would be enhance the services to bilingual patients.

Mobile phones: Shared tool. They get lost. Lose connection.

Messages sent to patients are for reminders, notifications, and supportive services. Patients can also query the database for information on their lab results from their phone. This information now becomes accessible without having using the Internet. I found that to be ingenious. It helps the patient take ownership and manage their disease directly from their phone. Supportive or lifestyle messaging seems to have a positive effect. Additional areas of research might look at how GPS can deliver nutrition based messages to patient at the point of need. Point of need would track patients coordinates and send a message making on making a healthy choice for lunch. Ideally, all the McDonald’s and Burger King’s in a geographic area would mapped to help facilitate this messaging to patients.

mHealth has a broad application. It’s a low barrier entry tool that connects end users to information at any time. Mobile phones and SMS texting have a place in public health communication strategies.

Can this model be replicated for women that are infected with HIV? Onward to find out from the Women’s Clinic. The Women’s clinic provides primary care services to HIV/AIDS impacted women and youth. I am very interested to see if a similar service has been deployed to this population.

Questions to ask:

What about using Twitter to get health information to patients and clinicians? Do you clinicians tweet to each other?  Do they tweet to their patients? Do they have time to tweet health information? SMS messages can be automated and sent out. Can you automate tweets?

SMS messaging and electronic heath records aren’t separate functions. Dr. Kahn demonstrated that it’s an integrated information flow. Key finding report that the database and CRM tool needs to work together. These functions are interdependent not independent systems.

HIPPA issues. Dr. Kahn’s patients consent or opt-in to his service. He brought up an excellent point that a text message is no less private then a fax or voice message that exchanges heath information between patient and provider. Learning more about the consent process and patient privacy issues should be investigated to gain more a greater understanding in this area.

Learning about Dr. Kahn

Bits and Queries:

Tonight I read Dr. Jim Kahn’s biography on the UCSF Global Health Sciences website. Kathleen and I are meeting Dr. Kahn at 9am at his office.

Dr. Kahn has three main areas of expertise.

1)    Policy Modeling in healthcare

2)    Cost-effectiveness Analysis

3)    Evidence based medicine

His work focuses on the use of cost-effectiveness analysis to inform decision-making in public health and medicine.  His expertise has been applied in economic evaluations of HIV prevention and treatment interventions in Africa and Asia. He is a PI for a review of synthesis of the effectiveness of US funded global health initiatives. He is the Director of Health Policy Program of the UCSF Clinical and Translational Science Institute. He’s been funded by NIH, UNAIDS, World Bank, other international government agencies and private foundations.

He’s published in general medical, AIDS, infectious diseases, reproductive health, and health policy academic journals. I am interested in learning about his work in Africa and Asia. I want to learn about his experience in cost-effectiveness analysis for SMS messaging services and HIV prevention and treatment interventions/adherence programs in Africa.