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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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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.