For Jonathan Ware, M.D., the best mHealth app is the one in his pocket.
The medical director of population health management at Florida's Orlando Health carries PT Pal around with him on his iPhone. The physical therapy app, which is also available for Android devices, can be used by patients on their own or in concert with their physical therapists.
Ware's job responsibilities at the nonprofit healthcare system, in addition to hospitalist rounds and managing four accountable care organizations, includes introducing new medical devices and programs into various departments. After using PT Pal himself, he's getting it into the hands of his physicians and physical therapists.
But like many busy people currently rehabbing an injury, Ware doesn't have a lot of free time to go to PT. So he's using PT Pal to rehab -- often on work time during short breaks -- a twisted left ankle he suffered in April rushing down a flight of hospital stairs.
Pilot planned for pediatric PT practice
I was going a bit nuts. I thought there had to be an app for this. I couldn't find it, so I built it.Naveen KhanCEO, PT Pal
And he'll soon observe PT Pal in action in a pediatric clinic trial overseen by John Dimino, manager of acute care and outpatient rehabilitation services at Orlando Health's Arnold Palmer Hospital for Children. One advantage of the app for pediatric patients with disabilities such as cerebral palsy is that patients, their caregivers and therapists will be able to record videos of their own movements andaccess them in the app, instead of trying to reach what could be an unattainable ideal presented by a model, Ware noted.
Ware says PT Pal makes it easy for him, and Orlando Health patients, to understand the sometimes tricky exercises in the physical therapy canon. Traditionally, therapists send their charges home with printed pictures of the movements, most of them derived from 1980s vintage stock and which many patients find hard to follow and easy to lose -- contributing to high non-compliance rates in many PT settings.
"Some of our physical therapy patients drop out. Those who show up for appointments only retain about 40% of it," Ware said. "A lot of them leave the paperwork in the car and find it three weeks later."
Gentle reminders of tough rehab work
PT Pal also reminds users when it's time to do their PT work, a gentle reinforcement mechanism that is a key part of the mHealth methodology, akin to the buzzes and blips that popular consumer devices such as the Jawbone UP and Fitbit bands use to remind wearers they've been immobile too long.The program actively supports such patient engagement by actually making the hard work and occasional tedium of physical therapy sometimes approach fun, Ware said.
"It's nice to see a video of what you're doing, or a picture," Ware said. "And it's really nice for me to have the reminder. It's like having the iPhone schedule it."
The story of PT Pal's inventor and CEO, Naveen Khan, a Los Angeles resident, dovetails with Ware's and others' frustrations with the limitations of traditional physical therapy.
The British-born Khan -- who met Ware and introduced him to her product at a February HIMSS conference in Orlando -- imagined the app when she was rehabbing from a bone marrow biopsy but was too busy at her management job at a big company.
"I couldn't fit in my PT," Khan said. "I was going a bit nuts. I thought there had to be an app for this. I couldn't find it, so I built it."
U.S. clinics sign on
That was a little over a year ago. Now, PT Pal has more than 200 individual users and is in place in more than 25 U.S. clinics and hospitals. Khan, meanwhile, says she has a number of deals brewing.
A new version of the program was released in July that is optimized for the iPad and adds video recording, among other features. The app now hosts videos of about 400 different PT exercises. Khan is planning to add new capabilities in future updates, such as game-like features for pediatric patients.
Khan and company CIO John Dzivak tout other benefits for the technology that mesh with trends in the EHR and mHealth worlds.
One that stands out is compliance, the lack of which is an oft-observed major drawback of physical therapy. Many PT clinics lack tracking capabilities to monitor how many of their prescribed exercises patients are doing, not to mention electronic records of their progress at home.
Dzivak pointed out that insurance companies and doctors and therapists themselves perhaps ought to be able to know patients' compliance rates. Each exercise has its own CPT (Current Procedural Terminology) code, so payers can track compliance rates by specific exercise.
"One of the goals of PT Pal was to get people to do their exercises," he said. "Payers have been interested in the compliance rate. They're paying for the rehab. If I'm a payer, I don't want to know what was prescribed. I just want to know the percent that was completed. Before, it was just anecdotal."
Potential side benefit: Meaningful use compliance
Another benefit of the app is the ability it gives patients to contribute to their own electronic health record by noting and recording their own PT exercise activity, Dzivak noted. One of the criteria for stage 2 of the Centers for Medicare and Medicaid meaningful use is allowing patients to do that.
Khan, who is also trained as a lawyer, said in addition to healthcare reform issues, devising the program for herself originally came down to a simple issue.
"As a single mom working for corporate America, PT Pal provided the ability to do [physical therapy exercises] anytime, anywhere," she said.
Necessity breeds solutions. mHealth Games, is a perfect
example of how creative efforts to solve a problem can generate powerful
solutions that work. Picture perfect innovation. Cost effective tools developed
by and for those on the front lines. Disruption of the greatest kind.
In August of 2013, I was given an opportunity to design and
implement an ICD-10 training program for a large managed care organization in
Miami. This is not as easy as it may sound. Most coders, including myself, have
been doing it for so long that we think in code. The idea of having to retrain
our brains as well as our providers was almost an unimaginable task. Knowing
this I quickly realized the one variable that would ensure success was the
ability to create content that would engage everyone. But how?
This particular organization spanned 4 states and 3 time
zones. Efficiency was critical. The ability to monitor and measure the amount
of engagement on a daily or hourly basis would provide the intelligence that I
needed to modify, adjust and improve the content. I knew what I needed to
succeed, but could I execute?
Creative content is what activates consumers to engage over
and over. It is what keeps them coming back. I am not an IT person. I have no
technical training at all, other than that which was required to graduate. How
was I going to pull this off? I could hire a company who specializes in IT or
even e-learning, but would that accomplish my goal? No, although experts in
their field, they lacked the experiences of a coder, and that was what I knew I
could capture my audience with.
So we started experimenting with tools to engage. The first
one took over two weeks. I took the top 200 ICD-9 codes and mapped them
backwards and forwards to the corresponding ICD-10-CM codes. I added specific
conventions to each mapping and added tips for clinical documentation. I
thought I had knocked it out of the park. I sent the final project out and
waited for feedback. I kept waiting and waiting, until I finally realized that
even as great as the tool was, it wasn’t applicable to what we were doing
today.
So, I came up with a better idea and requested the top 20
codes from each of their providers. With this new information I was able to
create a personalized training program for each provider. Surely, they would be
interested in learning about the codes they use on daily basis and how to
mitigate any impact to their revenue. But again, I was wrong. This still wasn’t
able to truly engage at the level I needed to succeed.
At this point, I was desperate for a better way and turned
to Google to research alternative methods. I spent at least 200 hours reading
about technology and how it is being used in distance education. What I found
was amazing! Really smart people had created amazing tools that would allow me
to work with technology. That was a defining moment! A change in paradigm had
occurred. I was no longer dependent upon others to close the gap between what I
wanted to create and what I was capable of creating.
This is where the fun begins. I had found the tools and now
it was time to really start creating engagement. Had I of known the complexity
of trying to learn new software, design games and teach ICD-10 - I may not have taken the challenge. This is actually much harder than it sounds,
but the results were well worth the time, talent and energy!
The learning curve was steep and fast. I can not tell you
how many times I considered quitting, but then I would look at the results and
I knew this had the potential to change everything! Why? Because these games
are not just games. They are published using the xAPI or “experience API”. This
means that we now are able to learn as much about our learners as they are
learning from us!
Consider, the power of one game and the insight of data it
could provide. The traditional tracking methods of pass/fail have now been
replaced by the ability to visualize when a learner has both interacted with
the concepts and mastered them. Thus creating an individual path to success!
These are the tools of the future! They create the
foundation for the new learning health care system, but most of all they
provide high value at little cost. We already know that games activate consumer
engagement, but the time to market and cost of production complicated the
process and reduced the return on investment.
Over the last few weeks, I have spent hours upon hours
discussing the potential impact on consumer engagement and the potential value
of taking mHealth Games to the next level. I have listened to stakeholders from
every end of the ecosystem describe their version of how, why, and what this
expansion could look like. Opportunities that I never thought possible have
been discussed with people who can actually make them happen. But what if we
choose to grow organically, where we continue to have to the freedom to create,
deliver, modify and improve? After all we have just begun.
The single greatest take-away from this week was how every
conversation of “growth” had the same plan, “By partnering with us, we will be
able to bring in engineers and you won’t have to design games anymore!” But doesn’t
that defeat the entire purpose of this journey?
The focus of modern healthcare is around lifestyle issues
such as obesity and diabetes. Picture: PA
by
GRANT CUMMING
Published on the 16 April 2014
Patients can be taught self-care, says Grant Cumming
A new building named the Alexander Graham Bell Centre,
located on the campus of Moray College UHI in Elgin, will be officially opened
in June to further the pioneering work already being done in the area on
digital healthcare or e-health. Detailed attention has been paid to the
internal architecture because the centre’s purpose is to bring together – and
create a flow of ideas between – people working in digital healthcare in the
public and private sectors as well as medics, social workers and academics.
Drawing on the “social physics” ideas of Massachusetts
Institute of Technology, professor Alex Pentland, among others, the centre will
be a hub for developing new and innovative ways of providing healthcare using
information and communication technology (ICT).
Social physics outlines how human behaviour is driven by the
exchange of ideas and learning from each other. It also identifies how large
amounts of very specific data available on the internet through different types
of computer technology can be used to help this process.
For example, one in four people in Moray consults the
internet prior to visiting their GP, giving doctors an insight into the value
of highlighting credible sources of information to patients which
might allow them to look after themselves.
We can no longer afford to deliver healthcare under the
existing model. Our system was built to deal with infection and while we will
always have infection, the focus of modern healthcare is around lifestyle
issues such as obesity and diabetes.
The traditional model is reactive when we need to be
concentrating much more on preventative and personalised medicine – we need new
ideas on how we engage with a person and their wellbeing throughout their life
and that is what the centre is there to generate.
In part, the challenge is subtly to alter the behaviour of patients.
As well as Alex Pentland’s, the work of behavioural economists Richard Thaler
and Cass Sunstein on nudging people to take action and that of psychologist
Daniel Kahneman, whose global bestseller Thinking Fast and Slow contrasts fast,
instinctive and emotional thinking with slower, more logical thinking in human
decision-making, has been influential.
We can teach people to look after themselves. We need an
element of nudging – persuading people to take action, for example by
highlighting the dangers of smoking. We also need budging – making people take
action, for example the ban on smoking in public spaces. We can use information
and new technology, perhaps even gaming, to create, for instance, a fun way to
exercise to get a message over to some groups.
The internet is now a social web where we can order goods
and interact with people, where information within documents can be linked and
disparate databases mined for more information.
We must look at how we can connect and collaborate and use
that technology to improve the delivery of healthcare, and where better to
develop that format than here in Moray?
Moray has already won global recognition for its excellence
in the field of digital health, hosting a World Health Organisation conference
on the subject in 2012. And two of the four projects in the UK to have received
substantial funding under the DALLAS (Delivering Assisted Living Lifestyle at
Scale) scheme are in Moray.
They are:
n Year Zero, an online application which enables people to
manage their health information and includes an online family tree, a digital
version of the red book that is given to all parents to record their child’s
health and Rally Round, a social networking and planning tool to connect
family, friends, carers and health and care professionals.
n Living It Up, which uses connected TVs to give people
access to health and community information within their own homes. Moray is the
test bed area for the project.
The whole place will be a melting pot for ideas, a safe
space in which we hope we will be able to redesign how we deliver healthcare.
• The £6.5 million Alexander Graham Bell Centre has been
funded by Highlands and Islands Enterprise, Moray College UHI, NHS Grampian and
the European Regional Development Fund.
Professor Grant Cumming, Consultant Obstetrician
and Gynaecologist, Dr Gray’s Hospital, Elgin is one of the medical
professionals behind the creation of the centre.
