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DEVELOPMENT OF A HEALTHY EATING KIOSK-BASED FEASIBILITY STUDY

IN A PUBLIC HEALTH PRIMARY CARE CLINIC

140th American Public Health Association2012 Annual Meeting

Health Informatics Information Technology

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WSU RESEARCH TEAM

Julie Gleason-Comstock, PhD, MCHES, PI and Assistant ProfessorDepartment of Family Medicine & Public Health Sciences (DFMPHS) Wayne

State University (WSU)

Nancy T. Artinian, PhD, RN, FAHA, FPCNA, FAAN, Co-PI, ProfessorAssociate Dean for Research, Director of Center for Health Research

College of Nursing, WSU

Catherine Jen, PhD, Co-PI, ProfessorChair, Department of Nutrition and Food Science, WSU

Alicia Streater, PhD, Co-PI, Research Associate Center for Urban Studies, WSU

Presenters Disclosures“No relationships to disclose.”

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RESEARCH MENTORED STUDENTS

Suzanne Baker, PhD, DFMPHS, MPH CandidateBosede Joshua, MBBS, MPH, DFMPHS

Kristin Oneail, RN, MSN, Nursing PhD CandidateDeborah Slago, RN, MSN, Nursing PhD Candidate

Jessica Timmins, Honors Nutrition & BiologyAndy Paranjpe, MD/MPH 2011-2016

www.cvri.med.wayne.edu_trainees

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RESEARCH PARTNERS

PRIMARY CARE

City of Detroit Department of Health & Wellness PromotionHerman Kiefer Adult Primary Care Clinic

TELEHEALTH

American TeleCare and LifeView

www.americantelecare.com

www.LifeviewTransform.com

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LEARNING OBJECTIVES

•Describe the development of a telehealth education study

•Assess the feasibility of integration into a primary care clinic

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CARDIOVASCULAR DISEASE PREVENTION AND HEART HEALTH

Heart disease & stroke are 1st & 3rd leading causes death for men & women men (33.6% all U.S. deaths), yet among the most preventable

•2010 cost of CVD in U.S. estimated @ $444 billion; about $1 of every $6 spent on healthcare

http://www.cdc.gov/chronicdisease (2012)

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CVD DEATH RATES•Age-adjusted death rates for CVD are 37%

higher among African-Americans than Whites

•Risk of having a stroke is nearly 2x higher for African-Americans than Whites

http://www.cdc.gov/chronicdisease (2012)

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CVD PREVENTION SAVES LIVES•Healthy lifestyle, including healthy food

choices, and a healthy weight reduce risk of developing heart disease/stroke

•Preventing and controlling blood pressure also play a significant role in CVH

http://www.cdc.gov/chronicdisease (2012)

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CVD - USA CHALLENGE•Nearly 68 million adults have high blood

pressure & about half do not have this condition under control

•Estimated 71 million adults have high cholesterol & nearly 2/3 do not have this condition under control

http://www.cdc.gov/chronicdisease (2012)CDC 2012. Vital signs awareness and treatment of uncontrolled

hypertension among adults 2003-2010. MMWR 61(35) 703-709. Accessed Sept 7, 2012.

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NATIONAL PREVENTION STRATEGY 2011 PLANClinical and Community Services

Recommendations

• Support National Quality Strategy’s focus on improving cardiovascular health.

• Expand use of interoperable health information technology to improve preventive services, quality of care & reduce health care costs.

• Support implementation of community-based preventive services & clinical linkages .

• Reduce barriers to access clinical & community preventive services.• Enhance coordination & integration clinical & behavioral health,

including telemedicine.

National Prevention Council (June 2011). Clinical and Community Preventive Services. National Prevention Strategy. http://www.healthcare.gov/center/councils/nphpphc

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RELEVANCE OF HEALTH REFORM TO HEALTH INFORMATION TECHNOLOGY

Improvement of quality of healthcare by increasing quality data collection, creating new programs, and payment to existing entities for improvement. 1

1 Patient Protection & Affordable Care Act (PPACA, H.R. 3590): Summary of Key Health Information Technology Provisions, June 1, 2010 www.himss.org. Accessed January 26, 2012.

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HEALTH REFORM AND TELEMEDICINE STRATEGY

Response from American Telemedicine National Health Reform Timeline and Telemedicine Public Policy Papers (2011)

▫ Telemedicine should be one component of any national strategy to increase access, improve quality and lower the costs of healthcare. http://www.americantelemed.org

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TELEMEDICINE AND TELEHEALTH

•Telehealth is within the family of telemedicine electronic communication & information technology

•It encompasses broader application, such as distance education & consumer outreach to support healthcare services. 1

1 American Telemedicine Association. (2006) Telemedicine, Telehealth and Health Information Technology: An ATA Issue Paper. http://www.americantelemed.org

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TELEHEALTH TECHNOLOGY • Kiosks are one example of telehealth technology.

• Computer-based systems designed to facilitate information access & exchange, enhance decision making , provide social and emotional support, & help behavior changes that promote health and well-being. 1

1 Or C, Karsh B-T (2009). A systematic review of patient acceptance of consumer health information technology. J of the Amer Informatics Association 16 (4): 550-556. doi:10.1197/jamia.M2888

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UTILIZATION• Potential for using consumer health technology to

improve health has been acknowledged, but technologies are not always accepted by patients.

• Reasons can include device usability, computer skills and low self-efficacy.

• Evidence shows substantial numbers of potential users, including those underserved by the health system, do not accept consumer health information technology. 1

1 Jimison H, Gorman P, Woods S, et a . Barriers and drivers of health information technology use for the elderly , chronically ill, and underserved(2008) Evid Rep/Technol Assess 175. AHRQ Publication No. 09-E004. Rockville, MD: AHRQ.

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RESEARCH POTENTIALHealth information technology studies are needed that examine

variables predicting consumer acceptance, including identifying factors which:▫ Create acceptance for the technology▫ Develop & evaluate the ability of applications to fulfill consumer

expectations▫ Increase the likelihood of technology implementation success. 1

Literature review related specifically to health kiosks identified a role for integrated kiosks as part of patient flow, e.g., physical monitoring or planned education. 2

1 Jamison et al, (2008), Barriers of HIT for elderly, chronically ill & underserved, AHRQ.2 Jones R. (2009) The role of health kiosks in 2009: literature and informant review. Int J

Environ Res Public Health 6: 1818-1855. doi.10.3390/ijerph6061919

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Eating for Heart Health (E4H2): A Kiosk-Based Public Health Education

and Primary Care Feasibility Study

Cardiovascular Research Institute Isis AwardDepartment Family Medicine & Public Health

Sciences School of Medicine, Wayne State University

2010 – 2011

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HEALTH INFORMATION TECHNOLOGY: AMERICAN TELECARE, INC.

Telehealth company with affordable kiosk technology, experience in evidence-based chronic disease management & patient education.

▫Web-based orientation & training for multi-user station and peripherals

▫Real-time operational support

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TECHNOLOGY •Telehealth provider station with

administrator log-in to secure website.

•Kiosk multi-user station for multiple encounters with: ▫Interactive touch screen including audio

option▫Password protected log-in ▫Self-monitoring for weight/blood pressure ▫Health education modules

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RESEARCH DESIGN•Convenience sample 51 adults with BMI > 25 •Participant kiosk log-in over six weeks •Randomized into two groups of six sessions

▫Nutrition/Intervention (25 participants) Primarily diabetes education content Weight self-monitored via kiosk

▫General Health /Attention Control (26 participants) Hypertension, physical activity, smoking & stress

education content Blood pressure self-monitored via kiosk

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IMPLEMENTATION•Baseline and follow-up blood pressure &

weight assessments conducted by graduate nurses

•Demographic, healthy eating behaviors and satisfaction surveys conducted by nutrition and public health students

•Research faculty & students from public health, nursing and nutrition faculty cross-trained in cardiovascular health & telehealth technology

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RESEARCH PROTOCOL APPROVAL

•The research protocol was approved by the Wayne State University Institutional Review Board (IRB) and the City of Detroit Health Department Research Committee.

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PARTICIPANT SCREENING/BASELINE

18%

47%

35%

Body Mass Index25-29 (Overweight)30-39 (Obese)40-54 (Ex-treme Obesity)

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PARTICIPANTS Average age about 50 years old, primarily African-American and female.

About equally divided between education of high school/less, or some trade school/college. About half had annual household income of $10K or less; half between $10K - $35K.

Around three-quarters had used the internet in the past six months, and two-thirds of those at home.

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CLINIC VISITS •Clinic Visit Frequency

▫Every 2-3 months (49%)▫Monthly (18%) ▫New to clinic (14%)▫Other (19%)

•Waiting Time▫1-2 hours (41%)▫<1 hour (33%)▫3 or more hours (12%)▫Other (12%)

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KIOSK FEASIBILITY STUDY DEVELOPMENT

•Kiosk-based consumer health information technology was feasible in a primary care environment.

•Telehealth corporate - academic partnership resulted in a health education pilot with an underserved population.

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PRIMARY CARE CLINIC INTEGRATION

▫Short, flexible kiosk sessions did not interrupt patient visits

▫Participants returned for multiple kiosk sessions

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FUTURE STUDY DIRECTIONS• Expand from primary care clinic to health

systems environment • Develop Community Health Worker/Peer

Educator CBPR training curriculum• Integrate consumer health information

technology into multiple kiosk/interactive website/tablet/smart phone

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SCREENING FOLLOW UPINTERVENTION

Baseline

BMI>25

Blood Pressure

Weight

What Are You Eating

3 MONTHS

6 Sessions

OUTCOMES

Pre-T

est

Post

Test

(2

mon

ths)

Nutrition Modules Weight

General Health

Modules Blood

Pressure

KioskSessions

Survey

What You Eat

MyPlate.gov

EATING BEHAVIORS

Weight

Blood Pressure

E4H² TeleHealth Feasibility Study