Social media use is one of many innovations in care delivery transforming the frontlines of care
For many of us, medical innovations mean genetically engineered drugs, novel devices like neuroprosthetic brain implants, and cutting-edge procedures such as robotic surgery. But a new type of innovation is also transforming the frontlines of care—innovation in how care is delivered. These innovations range from telemedicine visits with sick children while they are at school to use of social media to deliver therapy and manage and monitor chronic disease.
These innovations are profiled on the Agency for Healthcare Research and Quality's (AHRQ) Health Care Innovations Exchange Web site (http://www.innovations.ahrq.gov). The site offers busy health professionals and researchers opportunities to share, learn about, and ultimately adopt evidence-based innovations and tools suitable for a range of health care settings and populations. Individuals can report innovations and recount their successes and failures on the Web site. Others can learn from their innovations and/or offer comments, as well as participate in interactive Webinars and the Web-based discussion series, "Chats on Change."
"The focus is on changing service delivery or adopting an innovation in any setting," says Judi Consalvo, AHRQ Program Analyst.
Instant messaging to treat traumatic brain injury
"Social media innovations, such as instant messaging and mobile phone applications, can engage patients and improve their health," says Mary Nix, M.S., AHRQ lead on the Health Care Innovations Exchange project. For example, Thomas Bergquist, Ph.D., A.B.P.P., and his colleague, Sherrie Hanna, M.A., at the Mayo Clinic have investigated the feasibility of providing adults with moderate-to-severe traumatic brain injury with remote cognitive rehabilitation sessions to improve their memory and other cognitive functions.
Using an Internet-based secure instant messaging platform, an office-based therapist conducts the rehabilitation session with patients typically sitting at their home or library computer. During the sessions, the therapist and patient work through a memory notebook to improve memory. The patient can indicate emotions such as frustration or satisfaction during the course of the sessions via "smiley" faces, font color, or font size. After completing 60 online sessions, the pilot group of 14 adults were rated by their families as having fewer memory problems and better mood, as well as improved use of compensation strategies, such as calendar use.
Notes Dr. Bergquist, "One of our participants with a history of severe traumatic brain injury from a motor vehicle crash several years ago reported that the calendar training she received helped her to better structure and organize her life. This allowed her to feel a better sense of self-efficacy and mastery.... She told us recently, 'I still miss our times together.... I will forever utilize all the help and things I learned from you during our project!'"
Persons with brain injury often live far from specialized rehabilitation services and find travel-related activities challenging, so receiving therapy using technology such as instant messaging can potentially supplement some of their clinic visits, thereby reducing the burden. Also, once treatment gains have been realized in a traditional outpatient clinical setting, continuing treatment using this approach helps generalize those treatment gains into day-to-day life.
"This approach has the potential to provide treatment to persons who otherwise might not receive it," notes Dr. Bergquist. "Further research is required and there are still hurdles to overcome in terms of reimbursement and issues with cross-State licensure. For example, we could provide these services anywhere in the country, but health care professionals are typically licensed to provide care only in the State in which they practice. If the patient is located in another State from where the psychologist or practitioner is licensed, this would limit the ability to submit claims for those telehealth services." Dr. Bergquist also points out that the Centers for Medicare & Medicaid Services and many other private payers are reimbursing psychologists and other health care providers for telehealth services across the United States. However, Medicaid reimbursement varies from State to State.
Cognitive behavioral therapy via mobile phone
Driven by "an interest in interaction design to destigmatize therapy and make it more playful," Margaret E. Morris, Ph.D., of Intel Corporation, is developing and testing mobile phone applications that mirror cognitive behavioral therapy techniques for people to use who can't or don't want to see a therapist and as an adjunct to weekly face-to-face therapy sessions. These applications prompt individuals to assess their moods throughout the day and provide in-the-moment support. The touch-screen Mood Map, which Dr. Morris will soon test with larger groups on the Android and iPhone, invites people to plot their mood throughout the day and view trends to investigate what circumstances spark a drop or rise in mood. Based on their emotional state, individuals can select from a variety of self-directed therapeutic applications involving cognitive restructuring and relaxation exercises.
The Mind Scan exercise encourages cognitive reappraisal of thoughts that can lead to anger and depression. For example, one prompt asks the person to consider, "Might I be exaggerating the urgency of the situation?" In the breathing exercise on the application, a blue circle expands and contracts slowly to encourage deliberate and slower breathing, which may help reduce anxiety. The Body Scan includes an outline of a human figure with rhetorical questions about where the user might be holding tension, for example, "Are you furrowing your brow?" Participants can activate the breathing, Body Scan, and Mind Scan features directly or can select "coaching" to access a series of visual prompts for effective handling of interpersonal conflict. All of these exercises can be completed in a minute or less.
In a 1-month pilot study, participants described greater self-awareness of their emotional patterns. Based on these insights, many used the mobile therapies to improve specific relationships and deal more effectively with stressful situations. Case studies reported in a recent paper illustrate how these tools were used to manage personal and professional stress.
"The project was motivated by a need to extend the reach of psychotherapy—to bring therapy tools to far more people than those who have access today and to create short mobile experiences that are helpful in specific situations during daily life rather than or in addition to weekly therapy sessions," notes Dr. Morris. When asked about technology replacing human care, she responds, "I don't expect mobile therapies to replace or put psychologists out of business, but these tools may make their work more effective."
Dr. Morris points out that the therapy session is a snapshot in time, in which the therapist sees a person in a supportive environment. But how are they doing 2 or 3 days later in different circumstances? The mobile phone application allows a person to assess how they are feeling at any point in time. Tracking daily moods allows the person and the therapist to see a pattern over time and the person's strengths and weaknesses during certain parts of the day or in certain circumstances. For example, if a patient with social anxiety realizes from viewing her mood trends that she is most confident when walking home from work each day, she and her therapist may decide that this is a particularly apt time to practice social risk taking, such as initiating a conversation with a stranger. Ethan Gorenstein, Ph.D., of Columbia University, whose treatment protocols informed the mobile therapies, has also tested the application as an adjunct to brief cognitive therapy for anger reduction.
Individuals not in therapy may benefit from these applications as well. "I was impressed by how quickly people internalized the content and how creatively they applied it to the nuances of their lives," said Dr. Morris. She cites the example of one woman who used the conflict mapping and constructive confrontation exercises with her son to help process an argument that they had and his frustration with a teacher. Dr. Morris found that once individuals mapped and understood their own moods and reactions to situations, they started thinking about how they would map someone else's mood and started using it with their partners or friends to share Mood Map information and improve relationships. "Any tools we give people are going to be used interpersonally. The sharing that we observed in our studies makes me hopeful about the viral nature of these tools and their potential to benefit a lot of people," enthuses Dr. Morris.
Mobile phone management of adolescent asthma
A social media project to improve asthma control was led by Jonathan Mesinger, Ph.D., of the San Mateo Medical Center Asthma Project, and Gregory J. Seiler of BeWell Mobile Technology, Inc. They pilot-tested the mobile phone disease management application software developed by BeWell on 50 Hispanic adolescents with severe, persistent asthma. The patients recorded their symptoms on a mobile phone at least once a day by answering 20 questions in an electronic diary, which they found fun and convenient to use.
"The use of mobile technology for chronic disease self-management was a definite life-changer for some of our adolescent patients with asthma," comments Dr. Mesinger. "Since they were so comfortable with the technology already, the few who successfully completed the program actually were helpful in customizing the application for their own cohort."
Using their mobile phones, the adolescents keyed in their peak breathing capacity (peak flow meter reading), medication used, activity level, and symptoms such as wheezing. An asthma care coordinator received and monitored patient information. The goal was to better manage the adolescents' asthma to prevent exacerbations that can lead to frightening and costly emergency department (ED) visits and hospitalizations. The disease management platform allowed the coordinator to give adolescents instant feedback based on their electronic diary information. Patients could be rewarded or encouraged for stable health status, could receive a near-instant message on suggested changes to medication or other minor modification to their regimen if symptoms increased, as well as reminders to refill prescriptions, schedule tests, or order medical supplies. If the patient submitted information that indicated a risk to their health, for example, a substantial drop in peak flow, the nurse would alert the patient and typically call them about next steps.
After 8 months, this approach enhanced compliance with medication, which, in turn, led to better patient outcomes (e.g., improved average peak flow and less use of rescue inhalers). Patients also had fewer than five total unscheduled physician or ED visits for asthma-related conditions. By comparison, the typical child or adolescent with severe persistent asthma has three to five ED visits each per year. Participants missed an average of 0.38 school days per year due to asthma-related complications, well below the national average of 3.7 days for similar populations.
"Because many of our patients are monolingual Spanish speakers, the attention paid by BeWell Mobile in translating all the screens and instructions into Spanish was key to making this work, especially for the parents of the younger patients who participated," notes Dr. Mesinger. "If the application is available for every platform, so that any cell phone could be used to upload and download information from the portal, some of the initial hurdles related to cost and access could be overcome. Increased widespread use of mobile technology at all levels of society makes this application a critical piece in patient care and empowers patients to control and report on their own health."
AHRQ's Health Care Innovations Exchange (HCIE)
(http://www.innovations.ahrq.gov)
•HCIE project began September 2006 and HCIE Web site went live April 2008.
•Panel of 13 experts and 8-member Editorial Board provide guidance to HCIE (http://www.innovations.ahrq.gov/about/experts).
•Searchable database of more than 550 innovations and 1,575 quality tools that can help solve problems, improve health care quality, and reduce care disparities.
•The database can be searched by medical condition, population group, setting or stage of care, care process, quality tools, and other categories.
•Includes Webinars and Webbased discussions, "Chats on Change."
•Hosts the Community Care Coordination Learning Network, which helps communities identify and connect at-risk populations to needed care.
•AHRQ supports some innovations, but many are supported by other organizations.
•You can submit an innovation or quality tool or send questions or comments to info@innovations.ahrq.gov.
Research Activities, May 2011: Feature Story
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