Faced with a rapidly aging population, an increase in chronic health conditions and ballooning health-care costs over the same time period, governments and health system administrators are looking for solutions to ensure everyone gets the care they need. They are turning to the work of researchers who are re-deploying ‘everyday technologies’ such as text messaging as tools to prevent and manage chronic diseases in large populations of patients.
When used creatively, technologies that are already embedded in our daily lives can offer simple, low cost and user-friendly solutions with the potential to improve care, increase efficiency in the health system and offer patients the support they need, when they need it.
In this issue of Spark, we explore the work of three MSFHR-funded researchers using mobile health technologies to better understand and support their patients. Their stories illustrate how, by putting existing, user-friendly tools to use, we can find creative solutions to real world problems.
Roger Stoddard* is a health care advocate who has had six extended in-patient stays, the longest lasting almost two years.
“Even though I’ve moved between hospitals and home many times, the transition doesn’t get easier for me or my family,” says Roger. “I still feel a lot of guilt for getting ill, and the impact it has had on my family. Transitioning back home is a particularly difficult time. For me, one of the most important things is feeling supported and able to take control. That has a huge impact both physically and psychologically.”
Dr. Kendall Ho and his team of researchers in UBC’s Department of Emergency Medicine are working to support patients like Roger during this difficult transition period.
Using home monitoring technology provided by TELUS Health, patients measure their own weight, blood pressure, pulse and oxygen saturation, and this data is sent automatically to a nurse who can check the measurements and follow up if needed.
For some patients, the reassurance of knowing there is someone keeping an eye on their health who can spot potential problems and intervene early, can mean peace of mind and fewer unnecessary emergency department visits. For clinicians, the data provides extra clues about how a patient is doing.
“This kind of remote monitoring provides a foundation for conversations about health behaviours,” explains Ho. “If we spot a change in a patient’s measurements, we can probe to understand why and go beyond the information they might volunteer themselves. That deeper understanding helps us be more in tune with what that individual needs. Plus, being actively engaged in monitoring your health can help patients better understand their condition and optimize their own self-management.”
Although there is huge potential for using remote monitoring in health care there is still some uncertainty about the best way to use these technologies.
“I truly believe this type of technology has a big part to play in health care, but first we have to understand how to best introduce technology into both the health-care system and homes,” says Ho. “Then, as we understand more about the patterns in a particular patient, or a patient group, we might have the opportunity to predict the chance of deterioration.”
*Roger Stoddard is a member of the SPOR Primary and Integrated Health Care Innovation Network leadership council, a network of networks that is fostering a new alliance between research, policy and practice to support care integration.
In 2005, when Dr. Richard Lester and his team were starting an HIV treatment program in Kenya, the vast majority of his patients were starting treatment for the very first time. Not only that, they were spread out over a huge geographic area, with many in rural and remote parts of the country. The team knew adherence was going to be an issue, and needed to find a low-cost way to support patients to take their medicine, and take it correctly.
“We started by brainstorming with clinicians and patients and quickly found out that patients don’t want to be reminded to take their medication, they want to feel supported,” says Lester, an associate professor in UBC’s Division of Infectious Diseases. “Adherence is about more than just remembering to take your pills, it’s about the other priorities in your life - addictions, childcare, mental health – and how you balance all of these factors”.
The result was WelTel, a weekly text messaging service that makes use of widespread cell phone access in Kenya to simply ask ‘Mambo?’ (‘How are you?’ in Kiswahili).
According to Lester, a friendly ‘How are you?’ works because it isn’t intrusive but it opens the door to support if and when it is needed, without raising suspicion or sharing confidential information.
Halfway around the world, at BC Women’s Hospital’s Oak Tree Clinic, outreach nurses use similar weekly text messages to stay in touch with vulnerable patients. The clinic provides care for women and children living with HIV/AIDS across BC.
“The texts help build a bond between patient and nurse. Even though the first message is automated, patients know that there is a person at the other end who is there to help them,” says Dr. Melanie Murray, an infectious disease physician based at the Oak Tree Clinic. “It gives users the opportunity to ask for the support they need, whether that is ‘I need to reschedule my appointment’ or ‘I have nothing to eat’.”
I've learned to take my meds every day in the last six months. And it's a lot to do with being able to talk about it, through the texting. They let me know that the symptoms would go away, or just to hang in there and keep on trying. There's just somebody else there for me. In writing that you see it and it feels a hell of a lot better.Oak Tree client
[Getting a weekly text message] gave me a sense that someone was there, that there's actually someone there that will text me and ask me how I am. And even if it's once a week, it still makes a difference in someone's day.Oak Tree client
The greatest, um, thing I got out of that was really learning how to love myself and take care of myself, and value and appreciate myself and my life.
Okay. And that was through
the text messaging?
Yes, it was. It was a very valuable experience for me.Oak Tree client
Although patients still might not show up for their scheduled appointments, staying in contact gives clinicians the chance to identify and address problems related to treatment, or societal factors that impact physical and mental wellbeing, before they escalate into crises.
For Lester and his team, the next step is putting the hundreds of thousands of text messages they’ve gathered to work to improve health services. “The great thing about text messaging is that with relatively simple technology we can offer support to a large patient population and make better use of in-person visits. Initially, we focused on HIV and tuberculosis, but this approach can be applied globally for almost any condition, and has already expanded to include maternal child health programs in Kenya, and chronic disease care in Haida Gwaii.”
Although many people with prediabetes go on to develop type 2 diabetes, the risk of this happening can be lowered through positive lifestyle changes including a healthy diet and physical activity. But how do you help 5.7 million Canadians stick to a healthy eating and exercise regime?
Dr. Mary Jung and her team at the University of British Columbia Okanagan are studying how mobile health apps and lifestyle counselling can be used to change health behaviours for the better and maintain them long-term.
“There are over 150,000 mobile fitness apps on the market, but only 15% of Canadians get the recommended 150 minutes of moderate-to-vigorous physical activity per week, so we know something isn’t working,” says Jung. “We’re hoping to change this by showing app developers how to incorporate self-regulation and behaviour change science into their products and make real, long-lasting impacts on health behaviours.”
In Jung’s program, each patient takes part in a three-week training and counselling program and uses a customized fitness app to track and self-reflect on how they are performing against personalized diet and exercise goals. Once the three weeks is over, participants can still interact with their counsellor through the app to ask for help and advice, or show off their achievements.
“In this type of program you don’t need monitoring 24 hours a day, but you do need to feel some accountability,” notes Jung. “Just knowing the support of a counsellor is there at the other end of the app seems to have an impact, even if you don’t actually make use of that support.”
The Small Steps for Big Changes program, run in partnership with the YMCA Okanagan, aims to help 600 participants in the Kelowna area over a three-year period, and the app itself is evolving as the team learns more about how best to support and motivate users.
Jung adds, “My hope is that through our research we can generate enough strong evidence for apps that support real self-regulation that companies will recognize the benefit and incorporate behaviour change science into their apps. Mobile health has huge potential to help people manage various chronic diseases, but support apps need to be evidence-based and customized for different groups and individual users in order to realize that potential.”
Our three researchers are doing just that: using low-cost, user-friendly interventions to manage or prevent chronic conditions in large populations, while also identifying individuals who need more personal support and follow-up care.
MSFHR is committed to funding research that addresses these types of real-world challenges. Our new suite of programs support the generation of research evidence, provide opportunities for researchers to bridge the gap between research and practice, and explore how technologies can be used to improve the health and wellbeing of British Columbians.
For example, our Health Professional-Investigator Program supports health professionals who are actively involved in patient care to conduct and apply research derived from their practical experience and clinical expertise, while our Innovation to Commercialization Program is designed to help BC health researchers advance their discoveries or inventions towards practical application and bring to market products or technologies that improve health outcomes in BC.
As technology, and mobile health technology specifically, continues to evolve, we must continue to look for the simple, elegant solutions that solve real-world health problems and support a more effective and efficient health care system.
Dr. Kendall Ho is currently supported by an MSFHR Health Professional-Investigator award, Dr. Richard Lester is currently supported by an MSFHR Innovation to Commercialization award, and Dr. Mary Jung is currently supported by an MSFHR Scholar award.