08 October 2014

mHealth and mental health

In this post, I focus on how mHealth and sensor data are intersecting to promote mental health. Soon-to-be ubiquitous sensors in mobile devices can provide real-time data on sleep, activity, social interaction, isolation, vital signs indicating stress, and more. Some innovators want to utilize this data to improve mental health, illustrated by the following examples.

Mental health and academic performance
StudentLife, an app tested on Dartmouth students with their consent, provided insight into their mental health and academic performance. Andrew Campbell, a computer scientist at Dartmouth, states: “We found for the first time that passive and automatic sensor data, obtained from phones without any action by the user, significantly correlates student depression level, stress and loneliness with academic performance over the term.”

The researchers presented their findings at an international conference this month. The preliminary study monitored 48 students using this Android app over a 10-week period. The app automatically measured certain behaviors 24/7: sleep duration, number and duration of conversations per day, physical activity (walking, sitting, running), where they were located and how long they stayed there (dorm, class, gym, party), and more. The mobile device’s camera even measured when the lights went out.

Processed through computer algorithms, data acquired with the app was used to analyze mental health (depression, loneliness, and stress), academic performance (GPA), and behavioral trends (how stress, sleep, and gym visits change in response to college workload). The results obtained from the app correlated highly with information obtained in daily interviews.

Avatar provides motivational feedback
Designed for veterans undergoing physical rehabilitation after a debilitating injury, this app, dubbed PATRICIA (Personal Affective Therapist for Rehabilitation of Individuals with Cognitive Impairments), is still in development and early testing. Based on mobile sensors that provide real-time data, including heart rate and respiratory pattern, PATRICIA determines what motivational feedback is needed. Injured veterans could benefit greatly from such support when navigating difficult recovery after traumatic war injuries.

In addition to these examples, a number of other apps are appearing that utilize cognitive behavioral therapy (CBT) approaches to improve sleep and support positive behavioral change. This is an emerging area that needs further research. Questions about privacy will also need to be addressed, to ensure that users understand the goals of such data collection and what happens to the data that’s collected.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

01 August 2014

mHealth: What do we do with all the data?

Monitoring EKG rhythms with portable ambulatory monitors for 30 days improves stroke treatment, reports this month’s New England Journal of Medicine (NEJM).

Background: A leading, preventable cause of recurrent strokes is atrial fibrillation (AF), the most common abnormal heart rhythm and one that can cause clots to travel to the brain. It can be very difficult to initially diagnose AF because it tends to be paroxysmal, or “come and go.” So, it is a silent risk that easily evades detection. In recent years, continuously reported diagnostic data from implanted pacemakers and defibrillators has dramatically increased our knowledge of how prevalent AF is.

The trends are clear: Health care providers today and in the future will have unprecedented opportunities for ambulatory monitoring.
NEJM published results of a Canadian randomized clinical trial (RCT) that focused on patients who had strokes of unknown cause. It found AF was diagnosed five times as frequently in patients who wore special monitors for 30 days than for those who underwent conventional 24-hour testing. The findings led to better secondary interventions.

The ambulatory EKG monitors were attached to the chest with a non-adhesive, “dry” electrode belt. Patients were encouraged to wear it as often as possible over the course of 30 days. The study proved that this was a feasible and affordable intervention that improves care. The American Heart Association recently came out in support of prolonged EKG monitoring for “prevention of future stroke among survivors of ischemic stroke or transient ischemic attack.”

Imagine the monitoring possibilities we will have as mobile-device technology continues its exponential growth. Already, the mobile phone you carry in your pocket has more computing power than NASA did when it put the first man on the moon.

As reported in my previous post, the U.S. Food and Drug Administration has already approved a $200 case that turns your iPhone into an EKG monitor. But that’s barely the tip of the iceberg. Mobile monitoring services are the “dominant and fastest growing” segment within mobile health (mHealth) and revenues are projected to reach $49 billion by 2020. Click here to read the full report titled “mHealth Market Analysis and Segment Forecasts to 2020.”

The trends are clear: Health care providers today and in the future will have unprecedented opportunities for ambulatory monitoring. The question now becomes, “What do we do with all that data?”

Big data may be about to overwhelm the healthcare system,” writes Lindsay Alexander of MedCity News. “A little healthcare business intelligence tip: Data by itself won’t drive value and outcomes. Smart healthcare analytics will.”

Nurse leaders today must be creative thinkers. We must design the methodology and analytics to transform practice by using these technologies in ways that will change outcomes and improve health.

Technology is always changing, and existence of a new gadget will not necessarily impact care positively. The key to actualizing real and lasting change that matters is leadership, rooted in nursing knowledge and wisdom.

What are you doing to learn more about mHealth? What are your ideas about how these tools can improve practice?

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

18 June 2014

Wearable biometric monitoring comes of age

Wearable fitness technology is exploding. Today’s opportunities for biometric monitoring may surprise you, but what’s coming in the future could change how we practice health care.

In 2012, the U.S. Food and Drug Administration (FDA) approved a cellphone case which, for $200, turns your iPhone into an EKG monitor. This year, earbuds are emerging as the cutting edge of biometric sensors, because they maintain constant skin contact for best measurement.

Innovative new earbuds allow you to listen to music while monitoring your heart rate, as well as distance, cadence, speed, and calories burned in your workout. Furthermore, a small preliminary study at Duke University revealed that these earbuds can be used to accurately estimate total energy expenditure (TEE) and maximum oxygen consumption (VO2max).

Valencell is the clear leader in earbud innovation, but others will soon follow. Apple recently filed a patent application for its version of an earbud biometric sensor that measures temperature, heart rate, and perspiration levels. There is even an existing Apple patent for technology that picks up your telemetry as a “cardiac signal” that identifies you by measuring and remembering features of your waveform, such as the P-wave.

Why is wearable monitoring technology exploding right now? Sensors are becoming much cheaper, and the ubiquity and Wi-Fi connectivity of mobile devices is making them even more affordable. Now, instead of building in lighted screens and the larger batteries required to operate them, these monitoring devices just need to connect to the phone or tablet you already have. This lowers cost and increases functionality.

Also, the federal mandate around Electronic Health Records-Meaningful Use (EHR-MU) has begun to require that all patients have the ability to view, download, and transmit personal health data. Although this level of data portability for patients is still being developed, EHR-MU has lead to the creation of secure patient-data portals and mobile apps, such as Microsoft’s HealthVault, which is opening up huge opportunities for synergizing data between providers and the health-fitness apps and devices that patients already use. Meanwhile, the app market continues to experience exponential growth overall, especially in the “health and fitness” and “medical” categories (see comparison below).

Number of apps, by operating system, as of 17 June 2014.
Note: For each operating system, more apps are available for smartphones than for tablets. (Adapted from "AppBrain stats," "The mobile revolution is here," and "App store metrics."

Apple recently announced a promising innovation to collect and unify all of this information. This soon-to-come service, called “HealthKit,” will collect all your health data from apps, wearable fitness technology, even health care providers. Full details will not be revealed until their new operating system upgrade, iOS 8, is released this fall. Already, Android has announced its own “Google Fit,” also a health data aggregator service.

This continuing wave of innovation will change how we collect and use biometric data in the very near future. Instead of collecting a one-time snapshot of data collected on infrequent trips to a clinical setting, new technology allows frequent, even continuous monitoring, of people as they live their lives. More and more, patient-generated health data (PGHD) is being entered into the EHR through secure portals, increasingly through new apps and biometric devices. At a recent American Medical Informatics Association conference, the keynote speaker suggested that, “within 5 years, the majority of clinically relevant data … will be collected outside of clinical settings.”

With these innovations, opportunities for improved care include: 1) increased and more frequent patient data; 2) lower cost and increased availability of biometric monitoring equipment; and 3) increased involvement of patients in their own care.

There are also concerns. They include: 1) overwhelming providers with huge amounts of data; 2) loss of data security and privacy when transferring patient data from a HIPAA-secure portal to retail apps and mobile devices; and 3) possibility of compromised accuracy in collection of data.

What do you think of these new trends in biometric monitoring? I invite you to share your thoughts below.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

25 March 2014

Get ready for Blue Button!

Soon, every patient can click a virtual “blue button” to access, download, transmit—and sometimes even enter data into—his or her personal health record. As a health care provider, are you ready for the broader implications this change will bring?

It all began in August 2010 when U.S. President Barack Obama announced that, for the first time ever, veterans would be able to click a blue button on the Veterans Administration (VA) website to download or print their personal health records, or to share them with physicians outside the VA.

The program was so successful it quickly expanded to the MyMedicare.gov website; health benefit plans for all 8 million federal employees; and private insurers, such as UnitedHealth Group with its 26 million beneficiaries. And in February, five major pharmacy chains signed on to roll the program out to more than 20,000 stories nationwide (Brewin, 2013; Brewin, 2014). As adoption has spread from the public to the private sector, some have called Blue Button+ the “VA’s gift to the country” (Brewin, 2013).

Blue Button+ is now the blueprint for building an “ecosystem” of secure, online portals through which patients access, via websites and mobile apps, their personal health information (Sinai, 2014; Blue Button+, 2013). The U.S. government requires that all certified EHR providers, as part of Stage 2 of the EHR-Meaningful Use program, allow patients to securely view, download, and transmit personal data (Graham-Jones & Panchadsaram, 2013). Blue Button+ supports and expands this functionality. (Note: Some websites or apps using Blue Button+ standards do not explicitly communicate this to the consumer, but the functionality is there, even if there is not a literal—or virtual—blue-colored button.)

Although precise uses of Blue Button+ vary according to each institution’s policies, the program, in general, allows patients to:
  • Access health records to determine dates of shots or procedures.
  • Check accuracy of records, monitor changes, and stay aware of health status.
  • Share information with health care providers or others they trust, e.g., when traveling, seeking a second opinion, moving, switching insurance, or in an emergency.
  • Use apps to better manage and coordinate health care to achieve health goals.
  • Self-enter health metrics, such as weight, blood pressure, and heart rate, directly into their personal records (ONC, n.d.; Chopra, 2010).

Patients probably welcome this autonomy and control but, as a health care provider, you need to reflect on the broader implications. To help you do that, the next three posts in this series will explore emerging opportunities to:
  • Optimize patient health via this new ecosystem of health care apps and tele health tools.
  • Take advantage of patient access to health information to improve continuity of care and reduce costs.
  • Reimagine nursing’s unique role to maximize the contributions of these newly empowered patients.

On that last point, consider nursing’s role in treating human responses, promoting optimal health, and advocating for individuals, families, and communities (ANA, 2014). It is precisely in this realm—in this domain—that these digital, information-access tools empower patients. The professional nurse can serve as a coach-mentor in identifying appropriate health goals and tailored methods for reaching those goals, including apps and other emerging tools. In addition, the nurse has a powerful role to play in teaching patients how to collect and use data to advocate on their own behalf for best outcomes.

Digitally empowered patients will not use their newfound health-record access to diagnose medical conditions, order consults or procedures, or prescribe medication, as these functions are, rightly, the domain of the physician. But as nurses, are we preparing ourselves for an expanded role in this brave, new digital world? Our patients and the new health care system desperately need us to do that.

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.

American Nurses Assocation. (2014) What is nursing? Retrieved from http://www.nursingworld.org/EspeciallyForYou/What-is-Nursing

Blue Button+. (2013, February 4). Evolution of Blue Button. Retrieved from Blue Button + implementation Guide: http://bluebuttonplus.org/history.html

Brewin, B. (2013, October 1). True blue: VA’s gift to the country. Retrieved from http://www.govexec.com/magazine/nextgov/2013/10/true-blue-vas-gift-country/70994/

Brewin, B. (2014, February 10). Five major drug chains to adopt Blue Button prescription standards. Retrieved from http://www.nextgov.com/health/2014/02/five-major-drug-chains-adopt-blue-button-prescription-standards/78566/

Chopra, A. (2010, October 7). ‘Blue Button’ provides access to downloadable personal health data. Retrieved from http://www.whitehouse.gov/blog/2010/10/07/blue-button-provides-access-downloadable-personal-health-data

Graham-Jones, P., & Panchadsaram, R. (2013, February 5). Introducing Blue Button+. Retrieved from http://healthdata.gov/blog/introducing-blue-button

Office of the National Coordinator of Health Information Technology. (n.d.). Blue Button Connector: A way to help you find your health data. Retrieved from http://bluebuttonconnector.healthit.gov/

Sinai, N. (2014, February 7). Leading pharmacies and retailers join Blue Button initiative [Blog post]. Health IT Buzz. Retrieved from http://www.healthit.gov/buzz-blog/consumer/leading-pharmacies-retailers-join-blue-button-initiative/?utm_source=feedburner&utm_medium=feed&utm_campaign=Feed%3A+healthitbuzzblog+%28Health+IT+Buzz+Blog%29

10 February 2014

Let’s do this together!

Technology—it’s a term synonymous with innovation and change. Throughout my career, I have heard three consistent responses when the topic of adopting new technology in the workplace comes up.
  • “I have no idea where to begin.” 
  • “I have no idea how it really functions.
  • “I have no idea if there’s any way this could be used in my setting or with my patients.”
I believe solutions to overcoming these concerns lie in accessing peer communities, identifying best practices, and developing destinations that aggregate news, case studies, and insight. That’s why I’m writing this blog.

First, about me
A few words about my professional experience may help you understand this blog’s purpose and what you can expect to read in future posts. Throughout my life, I have considered myself a “tech” person and have learned to “just dive in” with new software, platforms, and digital tools. I have worked in many nursing settings: med-surg, ICU, code responder, hospice case management in both home- and long-term care, chemical dependency treatment, and informatics.

I have seen technology impact all these settings. I am also a nurse educator, and I tell new students that the first task in their nursing education is to “make your peace with change,” because this is a field where change is aggressive and never-ending. This is especially true when it comes to new digital technology and products.

Early adopters emerge from each generation. Young people enter the tech world with less baggage, anxiety, and historical expectations. They are not necessarily better at it than older generations; they just feel freer to explore and embrace new things, because of their shorter histories and less need to change previously held attitudes and expectations. Where a previous generation tends to leave off, they hit the ground running!

My philosophy
Nursing-related innovation should always be about improving patient care, and that includes both high-tech and low-tech innovation. This is not an either-or choice, and making it such creates an artificial and unhelpful dichotomy. Technology is not the answer to every question—sometimes pen and paper are best. But if we do not know what technology options exist, we can completely miss transformative opportunities to improve patient care—especially in the areas of self-care and health promotion. By using technology wisely, we have the opportunity to send patients home with a new set of tools that can revolutionize their understanding of their diseases and treatment plans, while providing more effective ways to engage in self-care.

We need to cross the divide between “techies” and nurses. The people behind digital technology reflect an immense, diverse, and rapidly expanding force that is both organized and organic. They need us to be fully engaged in spreading and creating the next generation of patient-care tools.

It can be hard for the busy practitioner to stay abreast of the latest news and trends, and this blog is one tool that will help you find and follow new developments. I hope to help you identify practical applications and demystify the tech process, so you can better share what you learn with your peers and social-media groups.

Moving forward
I want to start a conversation with you and the larger nursing community. Toward that end, I will seek to discover, aggregate, and share what is coming next. I want you to respond by asking questions and sharing your thoughts—by posting comments here and also on social networks. In today’s world, discoveries don’t come from just one source—the all-knowing expert. Each of us has a role to play. I will learn from you, and, together, we will make this blog a useful launch pad for further innovation and growth.

Please join me on the journey. I look forward to engaging with you!

For Reflections on Nursing Leadership (RNL), published by the Honor Society of Nursing, Sigma Theta Tau International. Comments are moderated. Those that promote products or services will not be posted.