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Web Applications & Mobile Platforms:Current Development & Next Steps
Robert Ciulla, Ph.D.National Center for Telehealth and Technology
Joint Base LewisMcChord/ Tacoma, WA
Agenda
•WebBased Applications
•Mobile Applications
•Challenges/ Future Directions
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Population HealthSERVICE MEMBERS(Defense Manpower & Data Center)
Active Duty 1,464,539
Guard/ Reserve 860,833
TOTAL 2,325,372
DEPENDENTS(Defense Manpower & Data Center)
Active Duty (Dependents) 2,044,055
Guard/ Reserve (Dependents) 1,158,120
TOTAL 3,202,175
VA PATIENTS(National Center for Veterans Analysis & Statistics)
Projected US Veteran Population 23,067,000
VA Unique Patients Treated FY09 5,744,000
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2008 RAND Study• Among OEF/OIF veterans, rates of PTSD, major depression,
and probable TBI are relatively high, particularly whencompared with the general U.S. civilian population. Atelephone study of 1,965 previously deployed individualssampled from 24 geographic areas found substantial rates ofmental health problems in the past 30 days, with 14 percentscreening positive for PTSD and 14 percent for majordepression. A similar number, 19 percent, reported aprobable TBI during deployment. Major depression is oftennot considered a combatrelated injury; however, ouranalyses suggest that it is highly associated with combatexposure and should be considered as being along thespectrum of postdeployment mental health consequences.
Invisible Wounds of War: Psychological and Cognitive Injuries, Their Consequences, and Services to Assist Recovery.Editors: Terri Tanielian and Lisa H. Jaycox. http://www.rand.org/pubs/monographs/2008/RAND_MG720.pdf.
Barriers to Care/ Stigma•While afterdeployment adjustment problemsare normal… Service members do not seekfacetoface care because of barriers (distancefrom a facility, scheduling and transportationchallenges)… And because of stigma (‘Areservices confidential?’ ‘Will I be diagnosed witha ‘mental illness’?’ ‘Will I be considered unfit toperform my duties?’)
•“Of those whose responses met the screeningcriteria for a mental disorder according to thestrict case definition, only 38 to 45 percentindicated an interest in receiving help, and only23 to 40 percent reported having receivedprofessional help in the past year. Thosewhose responses met these screening criteriawere generally about two times as likely asthose whose responses did not to reportconcern about being stigmatized and aboutother barriers to accessing and receivingmental health services.”
Combat Duty in Iraq and Afghanistan, Mental Health Problems, andBarriers to Care. Charles W. Hoge, M.D., Carl A. Castro, Ph.D.,Stephen C. Messer, Ph.D., Dennis McGurk, Ph.D., Dave I. Cotting,Ph.D., and Robert L. Koffman, M.D., M.P.H. NEJM, Volume 351:1322, July 1, 2004, Number 1.
Congress
• National Defense Authorization Act (NDAA) FY 2006, 2007(H.R. 1815), Title Vii, Subtitle C, Sections 721(b) & 722directed the DoD Military Health System to:
– Establish pilot projects to evaluate the effectiveness ofinteractive mental health material made available tomembers of the Armed Forces, their Families, and Veterans,as well as military and civilian health care providers.
– Improve the capability of the military health system toprovide early diagnosis and treatment of PostTraumaticStress Disorder (PTSD) and other behavioral conditions.
– Web portal enabling anonymous use
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WebBased Applications
• Access/ force multiplier• Privacy/ stigma• Convenience• Based on standards (write once, run anywhere)• Open systems/ no thirdparty approval• Pages and secondary pages and layers of info• Searchoriented• Form factor
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Design Elements
• Credible content• Engaging graphical
interface• Support learning style• Preclinical• Selfguided/ selfpaced• Privacy/ stigma• Immersive/ interactive• Multiple media• Scope (pathology/
wellness)
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afterdeployment.org:Landing Page History
August 2008
July 2009
March 2010
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afterdeployment.org
• 18 Topics• 29 SelfAssessments• Multiple Media Libraries• SelfPaced Workshops• VideoBased Personal Stories• Community Forums• Expert Blogs• Links to Hotlines• Links to Other Sites/ Content• Provider Locator Tool• Provider Portal• Podcasts• RSS Feeds• Polls and Quick Health Tips• Social Media Links• Daily Quotes
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Learning Management System (LMS)
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Provider Portal
• Launched December 2010• Info re: site’s assessments• Quick facts about PTSD and TBI• Client Handouts• Clinical Practice Guidelines• Topical Briefings• Links to Continuing Education• Resilience/ SelfCare re:
Secondary Trauma• New Look (to the left) Spring ‘11
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Online Coaches
• Online VideoBasedCoaching – Overview:– Provides engaging
human interfacebetween user andpsychological content
– Promotes ‘connection’between user andcontent
• Future Applications:– Videobased AI
introduces content,guides user
Presidential Study Directive (PSD9)
STRENGTHENING OUR MILITARY FAMILIESMeeting America’s Commitment January 2011
1.1.5. DOD will further implement counseling options that are free, convenient, and confidential toencourage selfinitiated treatment and improve military families’ quality of life. Preventive approaches oftenreduce the need for complex forms of treatment involving intervention and drug therapy. DOD will continueto enhance confidential nonmedical counseling via Military OneSource Counselors and Military Family LifeConsultants. Additionally, the Webbased TRICARE Assistance Program and telemental health programsare fielding telecommunication technologies to bring counseling assistance and behavioral health care tothose who need it most. The “Virtual Behavioral Health Program for Redeploying Soldiers” is an example ofthis type of counseling. It was established to maximize behavioral health assets and moderncommunications technology to provide uniform contact with all those redeploying. The goal is to identify carerequirements early but also help reduce stigma by encouraging and normalizing psychological health. Thiscapability has been deployed at Schofield Barracks, Fort Richardson, Fort Carson, Joint Base LewisMcChord, and Fort Stewart. DOD will also improve awareness of and further enhance its webbasedservice member and family outreach resources such as www.SuicideOutreach.org andwww.afterdeployment.org. The VA will offer lessons from their implementation of over 300 Vet Centersacross the United States and surrounding territories where Veterans and their families can find readjustmentcounseling and outreach services. Seventy percent of all widows of Operation Enduring Freedom andOperation Iraqi Freedom Service members have received counseling support at Vet Centers.
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WebBased Applications
Some Positives:• Access• Privacy/ stigma• Convenience• Open systems• Layers of information• Searchoriented• Form factor
Some Negatives:• Static pages• Aggregator sites• Variable design quality• Sustained attention• Lack of portability• Conveyor of psych info
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The Death of the World Wide WebWired, August 2010
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The Grateful Dead (Web)
• “You wake up and check your email on your bedside iPad —that’s one app. During breakfast you browse Facebook,Twitter, and The New York Times — three more apps. On theway to the office, you listen to a podcast on your smartphone.Another app. At work, you scroll through RSS feeds in areader and have Skype and IM conversations. More apps. Atthe end of the day, you come home, make dinner whilelistening to Pandora, play some games on Xbox Live, andwatch a movie on Netflix’s streaming service. You’ve spentthe day on the Internet — but not on the Web. And you arenot alone.”
– ‘The Web is Dead’ –Wired, August 2010
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Mobile Platforms• By 2013, mobile phones will overtake PCs as the most common
Web access device worldwide.
• By 2014, over 3 billion of the world's adult population will be able totransact electronically via mobile or Internet technology.
• Within five years, 70 percent of collaboration and communicationsapplications designed on PCs will be modeled after user experiencelessons from smartphone collaboration applications
• Websites not optimized for the smallerscreen formats will becomea market barrier for their owners — much content and many siteswill need to be reformatted/rebuilt.
http://www.gartner.com/it/page.jsp?id=1278413
Army ‘Go Mobile Program’“A Portal in Your Pocket”
http://fcw.com/articles/2009/12/11/armygomobilekitfitsportalinapocket.aspx
Mobile Devices: ‘On the Go’ Resources
• ‘Hippocket’ accessibility
• Scheduling and reminder capabilities
• Evidencebased tools and standardized content
• Realtime assessments (vs. retrospective assessments)
• Immediate selfmanagement of unexpected acute symptoms
• Immediate twoway contact with support systems during crisis
• Mitigate logistical barriers, supports treatment commitment
• Personalized and individuallypaced content
Leadership
• Gen. Peter Chiarelli… who spoke at Brookings Institution… saidsmart phones for the nation’s ground forces would provide soldiers a“tremendous advantage.”
• “I’m not into any particular smartphone,” Chiarelli tells DangerRoom,” I just happen to carry an iPhone for my own personal use… .We can already see the benefit for the squad and team leader.” Thatis, the rapid availability of data from across the Army, all over theworld, into a soldier’s mobile device — from intelligence reports todrone video to locallanguage phrasebooks — if the bandwidth isavailable.
http://www.defensesystems.com/Articles/2011/02/23/Armygroundtroopstoaccesssmartphone networks.aspxhttp://www.wired.com/dangerroom/2011/02/armywantslowlevelsoldierslinkedintoitsdatanets/#
Tactical Breather
•Fourcount breathingexercise
•Android and iPhone.
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T2 Mood TrackerReleased September 2010
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üSelfmonitoring behaviorchange strategies
üPatient compliance
üPencilandpaper techniques
üRetrospective reporting; ‘backfillling’
üElectronic diaries improve compliance
üSoftware prompts selfrecording (reminders)
üImproved datacollection accuracy
üGraphs reflect trends
üUserentered notes
üTherapeutic interventions
üVisual Analogue Scale (VAS) vs. Likert scales
üVAS combined with touch screen technology
üNot a psychological assessment
üOptimal benefits when used in tandem with provider
18 NOV 2010
Rate Categories via TouchScreen Technology
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Graphs and Notes
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CNN Interview: 11/9/10
26 18 NOV 2010
Breathe2RelaxReleased March 2011
• Handson diaphragmaticbreathing exercise
• Multiple Media• Psychoeducation• NarratorGuided• Selfassessment• Track Progress• Journaling and Health Tips
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Breathe2Relax: Feedback
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Mobile Applications ‘On the Street’
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Mobile Surveillance
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Smart Phone Apps: Development Typology
Service Member /Vet / Patient
PreClinical SelfAdministered Apps
ProviderAssistedApps
Support Provisionof EBP
Require ProviderOversight
Provider
Support Provisionof EBP
Support ProviderGrowth/Resilience
Improve Systems
ConcernedSignificant Others
Adults
Children
The Mobile Platform: Challenges
• Crossplatform development
• HIPAA
• Section 508 Compliance
• HTML5
• mHealth32
The World Wide Web: Dead…Wired, August 2010
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… Or RebornTechnology Review, Nov/Dec 2010
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Dead… or Reborn
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‘PreClinical’
• ‘SelfCare Solution’
• Behavior change is difficult
• Modal # of visits = 1
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User Interface
A Computer I Can Talk To
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IBM’s Watson“The computer on ‘Star Trek’ is a questionansweringmachine… It understands what you’re asking and providesjust the right chunk of response that you needed. When isthe computer going to get to a point where the computerknows how to talk to you? That’s my question.”
David Ferrucci, IBM’s Watson Project Lead; NY Times, 20 June 2010
The Challenges
• “Intended meaning”
• Not possible to handwrite a database that wouldencompass all human knowledge (‘boiling theocean’ )
• Last 10 years –algorithms statistically correlatingassociated words/ concepts
• Watson uses more than a hundred algorithmssimultaneously and ‘thinks’ probabilistically
Elementary…A computing system thatcan understand and answercomplex questions posed ineveryday natural language…Watson will incorporatemassively parallel analyticalcapabilities… like humans,Watson is not connected tothe Internet…
Where Google points to adocument where you mightfind the answer, Watson can‘pluck out the correctanswer itself.’
Watson knows only what isalready in its brain.
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Watson, M.D.
• “I want to create a medical version of this,”[JohnKelly, head of IBM’s research labs]. “A Watson M.D., ifyou will.”He imagines a hospital feeding Watson everynew medical paper in existence, then having it answerquestions during splitsecond emergencyroom crises.“The problem right now is the procedures, the newprocedures, the new medicines, the new capability isbeing generated faster than physicians can absorb onthe front lines… ” He also envisions using Watson toproduce virtual call centers, where the computer wouldtalk directly to the customer and generally be the first lineof defense, because, “as you’ve seen, this thing cananswer a question faster and more accurately thanmost human beings.”
Computers Learn to Listen, and Some Talk Back –(NY Times article, June 24, 2010)
… the disembodied likeness of awoman’s face on a computer screen
a nofrills avatar. Her words ofsympathy are jerky, flat andmechanical. But she has the right stuff
the ability to understand speech,recognize pediatric conditions andreason according to simple rules
to make an initial diagnosis of achildhood ailment and its seriousness.And to win the trust of a little boy
“… children and grandchildren willthink it is completely natural to talk tomachines that look at them andunderstand them,” said Eric Horvitz, acomputer scientist at Microsoft’sresearch laboratory who led themedical avatar project, one of severalintended to show how people andcomputers may communicate beforelong.
Avatar Applications• Initial site orientation. Avatar references
site content, links, and call centerfunctions.
• Assists with basic treatment/ curriculumplanning: when a user queries theavatar re: stress materials, the avatarwould describe a ‘best approach’ to thematerials (assessments, text, videos,workshops).
• The avatar ‘remembers’ the user acrossvisits, i.e., the user’s site usage history.
• During followup site visits, the avatar’sassistance becomes increasinglypersonalized and tailored to the user’spreferences.
• Over time, a rapport is establishedbetween the user and the avatar. Theavatar welcome’s the user, ‘reminds’ theuser of activities engaged in during thelast visit(s), and encourages the user toquery for more information.
• The avatar serves as a user’s datarepository, allowing the user to ‘check in’(with the avatar) and track prior siteactivity.
Next Generation
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‘Next Generation’ Features
• Centralize/ Customize/ Hybridize/ Modularize
• Emphasis on web video, mobile, social media
• Metasite hyperlinks within/ across silos
• Learning Management System (‘elearning’)
• Steppedcare model
• Crossplatform development
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Content Across Venues/ Platforms
Content Rules
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Web Novels
Games for Learning
Handheld Media Players
Smart Phones
Netbooks
eReaders
Tablets
Cell Phones
Cell Phones
Mobile Texting (SMS)Crisis Numbers
Health Tips
T2 Marketing
Inspirational Quotes
RSS Feeds
GroupSpecific Messaging
User/ Professional Q&A
Appointment Reminders
Communication with Provider
Peer Group ‘virtual text room’
LocationBased Game
Social Robots(NY Times article, July 10, 2010)
“Students, Meet YourNew Teacher, Mr. Robot”
“Computer scientists are developing robots likethis one: highly programmed machines that canengage people and teach them simple skills… ”
‘You Are Not a Gadget’
• “The most important thing to ask about anytechnology is how it changes people.”
Jaron Lanier‘You Are Not a Gadget’, p. 36
• Changing the height of an avatar in immersivevirtual reality transforms selfesteem and socialselfperception.
Stanford U. research finding(referenced in ‘You Are Not a Gadget’)
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afterdeployment.org Research Portal
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The Iconic ‘Couch’
Service Delivery in the 21st Century
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Program Partners / Stakeholders• VA National Centers for PTSD
• Army Medical centers: Tripler,Madigan, Brooke
• AMEDD Center / School PastoralMinistry Training
• TRICARE Management Activity,Health Affairs
• Navy Bureau of Medicine
• Real Warriors Campaign
• Defense and Veterans Brain InjuryCenter
• National Center for DeploymentPsychology
• US Army Preventive MedicineCommand (Prov)
• SPaRRC
Audience: All Service Branches, Reserves, National Guard, Family Members, Veterans, Providers
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Contact Information
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‘Virtual Handheld Clinic’
Robert Ciulla, Ph.D.Chief, Population & Prevention Programs |P3|National Center for Telehealth and Technology |T2|Joint Base LewisMcChord; Tacoma, WArobert.ciulla@us.army.mil
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