Post on 26-May-2020
transcript
Connected Health Technologies and Mobile Apps for Mental Health
Steven Chan, MD, MBAClinical Informatics FellowUniversity of California, San Francisco, School of MedicineSan Francisco, California
Co-investigatorUniversity of California, Davis, Psychiatry Virtual Collaborative Care NetworkSacramento, California
What is Telehealth?
American Telemedicine Association. www.americantelemed.org/main/about/about-telemedicine. Accessed May 30, 2017.
...Patient consultations via video conferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education, consumer-focused wireless applications and nursing call centers are just some of the related applications.
“
Why Should I Care? DIGITAL NATIVES
• Parallel processing & multitasking
• Prefer graphics & visuals• Instant gratification &
rewards• Prefer to be networked• Learn with information
fast, presented in a random fashion
Your patients may be one of these:
Prensky M. On the Horizon. 2001;9(5)1-6. www.marcprensky.com/writing/Prensky%20-%20Digital%20Natives,%20Digital%20Immigrants%20-%20Part1.pdf. Accessed May 30, 2017.
DIGITAL IMMIGRANTS
• Use Internet for information second rather than first
• Print out email• Share computer content
in-person• Learn slowly, step-by-step,
one thing at a time
Patients Want Digital Tools
Torous J, et al. JMIR Mental Health. 2014;1(1):e5. Naslund JA, et al. J MentHealth. 2015;24(5):321-332.
Harvard
LSUNew Orleans
UC DavisSac County
U Wisconsin,Madison
Study of psychiatric outpatients shows 58% own smartphones (mirrors US general population).
71.4% psychiatric outpatients favor the idea of using smartphones for mental health.
Younger patients & private insurance (vs publicly‐insured) tend to own phones & favor app use.
Severe mental illness patients can use & accept telehealth interventions. (Efficacy not established yet.)
There are better ways to track health.
Frost JH, et al. J Med Internet Res. 2008;10(3):e15.
Diazepam
Bupropion
Escitalopram
Zolpidem
Celecoxib
Albuterol
Cefuroxime
Mometasone
Ezetimibe
Anxiety
Constipation
Depression
Emotional lability
Telehealth advantages
Diagram by @StevenChanMD. Advantages: Morland LA, et al. Current Opinion in Psychology. 2017;14:102-108.
Overcome barriers: location, transport, provider availability, limited open hours
Cost-effective in some cases
Opportunity to revamp operations & promote QI
VALUEreduced per-capita
costs
POPULATIONImproved
population health
QUALITYBetter satisfaction & care experience
An Economist’s Point of View
Powell AC, et al. Child Adolesc Psychiatr Clin N Am. 2017;26(1):125-133.
• Potential direct benefits include– Substitution for other forms of care– Prevention of higher-acuity illness– Higher rate of psychiatrist use– Increased competition of services driving lower
treatment costs– Lower operating costs for psychiatrists– Fewer missed appointments– Revenue for application developers
• Potential indirect benefits include improved physical health, enhanced current and future productivity, and reduced demands on caregivers
Discovering Apps
1. For communications & coordination.
2. To augment diagnosis, treatments.
3. As new intervention & monitoring.
See Patients on These Telehealth Platforms
Not a comprehensive list. Accurate as of January 3, 2017.
Name Service Hiring
Doctors on Demand Video visits Physicians, psychologists
American Well Telephone & video visits Physicians
1DocWay Psychiatry clinics, psychiatry hospitals, emergency psychiatry
Psychiatrists
MDLive Breakthrough Video talk therapy Licensed therapists
Talkspace Text messaging therapy LCSW, LMHC, LMFT, LPC, Psychologist, etc.
BetterHelp Text messaging therapy LCSW, LMFT, LPC, PsyD, or similar credentials
CloudVisit Private practive video Multiple providers
Practice Guidelines on ATA
American Telemedicine Association. http://thesource.americantelemed.org/resources/telemedicine-practice-guidelines.
Messaging Apps
Communications apps
DON’T use consumer email
DON’T use consumer social media
GO USE enterprise secure email where you’ve signed a HIPAA-compliant “business associates agreement” (BAA)
GO CHECK with your organization’s IT, legal, & risk teams
GO SET boundaries & rules with patients & care team members
You can go beyond mood charts
http://mood-trek.com/consumer/. Accessed May 30, 2017.
Apps can do much more than replace…
Journaling
Paper charts
Education handouts
Discovering Apps
1. For communications & coordination.
2. To augment diagnosis, treatments.
3. As new intervention & monitoring.
VA App Store — https://mobile.va.gov/
PTSD = posttraumatic stress disorder; TBI = traumatic brain injury. http://t2health.dcoe.mil/products/mobile-apps; https://mobile.va.gov/appstore. Accessed May 30, 2017.
ACT Coach, Breathe2Relax, CBT-I Coach, Concussion Coach, CPT Coach, Dream EZ, LifeArmor, Mindfulness Coach, Moving Forward, PE Coach, Positive Activity Jackpot, PTSD Coach, Stay Quit, T2 Mood Tracker, Tactical Breather, Virtual Hope Box
US Department of Defense National Center for Telehealth & Technology (T2) and US Department of Veterans Affairs
Insomnia, PTSD, TBI, nicotine addiction, depression, anxiety
VA App Store — https://mobile.va.gov/
KEY POINT
Many non-profits, government agencies, & established institutions are more trustworthy than amateur developers.
Virtual Hope Box
CI = confidence interval; VHB = Virtual Hope Box.Bush NE, et al. Psychiatr Serv. 2017;68(4):330-336.
VHB users (n = 58) reported significantly greater ability to cope with unpleasant emotions and thoughts (Coping Self-Efficacy Scale) at 3 (b = 2.41, 95% CI = .29–4.55) and 12 weeks (b = 2.99, 95% CI = .08–5.90) compared with the control group (printed materials about coping with suicidality, n = 60).
Stay Quit Coach
Hicks TAB, et al. J Dual Diagn. 2017;13(1):15-20.
Smokers with PTSD express interest in and helpfulness of Stay Quit Coach for remaining abstinent after a quit attempt. KEY POINT
Tools can be combined with programs, but “adequately powered clinical trials” are still in the works.
GAD-7 = Generalized Anxiety Disorder-7; PHQ-9 = Patient Health Questionnaire-9.Mohr DC, et al. J Med Internet Res. 2017;19(1):e10.
KEY POINT
Coach-assisted apps can significantly reduce depression & anxiety.
Intellicare
Of the 99 participants who initiated treatment, 90.1% (90/99) completed 8 weeks. Participants showed substantial reductions in the PHQ-9 and GAD-7 (P < .001).
Neither baseline PHQ-9 nor GAD-7 were significantly related to changes in depression or anxiety severity, or concurrent treatment with psychotherapy or pharmacotherapy.
https://intellicare.cbits.northwestern.edu. Accessed May 30, 2017.
KEY POINT
Good apps & platforms must work together, involving data sharing & data interoperability.
IntellicareThought Challenger, Daily Feats, Aspire, Purple Chill, Worry Knot, Slumber Time, iCope, My Mantra, Day to Day, Boost Me, MoveMe, Social Force
Northwestern University
Target depression & anxiety
http://sam-app.org.uk/. Accessed May 30, 2017.
KEY POINT
Interventions can be interactive and guided, making them more exciting than static paper instructions.
SAMUniversity of West of England
Targets depression, anxiety
www.anxietybc.com/resources/mindshift-app. Accessed May 30, 2017.
Quanbeck AR, et al. Implement Sci. 2014;29;9:65.Marsch LA, et al. J SubstAbuse Treat. 2015;59:30-37.
KEY POINT
Internet-delivered education can be as effective as those delivered by specialists (eg, HIV prevention, substance use).
MindShiftAnxiety Disorders Association of British Columbia & BC Children’s Hospital
NAMI = National Alliance on Mental Illness.www.nami.org/Find-Support/Air-App. Accessed May 30, 2017.
Naslund JA, et al. EpidemiolPsychiatr Sci. 2016;25(2):113-122.
NAMI AIR (“Anonymous Inspiring Relatable”)
Social network for individuals & caregivers
KEY POINT
Social networks can challenge stigma, increase consumer activation, and boost access to well-being interventions.
Discovering Apps
1. For communications & coordination.
2. To augment diagnosis, treatments.
3. As new intervention & monitoring.
https://en.wikipedia.org/wiki/Machine_learning. Accessed May 30, 2017.
field of study that gives computers the ability to learn without being explicitly programmed
“Alcohol Relapse Monitoring
Dulin PL, et al. Subst Abus. 2014;35(2):168-175.
KEY POINT
Interventions can be done in the heat of the moment (vs current practice of waiting for a clinic visit).
Chat Therapy
Courtesy @MichielRauws2, @X2_AI
KEY POINT
New disruptive services try to fill in service gaps (eg, remote, dangerous locations & during evening & late-night hours).
HIGH PRIORITY
Alert the psychiatrist. Message to top of queue.
NEGATIVE SENTIMENT
NORMAL PRIORITY
Place message in queue.
POSITIVE SENTIMENT
NLP Example of Sentiment Analysis
Example script and diagram by @StevenChanMD. Sentiment analysis in https://cloud.google.com/natural-language/.
PATIENT MESSAGES CARE
TEAM
MESSAGE SENT TO SENTIMENT ANALYSIS NATURAL LANGUAGE
PROCESSOR
COMPUTER DECIDES ON MESSAGE
PRIORITY
I think my depression and irritation is getting worse.
My sleep is great. The exercise plan you …
Affective Computing & Avatars
http://ict.usc.edu/prototypes/simsensei/. Accessed May 30, 2017.
MultiSense SimSensei
Duke University + Apple ResearchKit Face Emotion-Detection for Autism
https://autismandbeyond.researchkit.duke.edu; https://today.duke.edu/2015/10/autismbeyond. Accessed May 30, 2017.
Serious Games Research ADHD &
Autism
Courtesy @VahabzadehMD. Anguera JA, et al. Transl Psychiatry. 2016;6(9):e893.
ADHD & Autism
SPD = Sensory Processing Dysfunction.Anguera JA, et al. PLoS One. 2017;12(4):e0172616.
Following the cognitive intervention (4-week iPad video game), only the SPD children with inattention/hyperactivity showed both improvements in midline frontal theta activity and on a parental report of inattention.
33% of these individuals no longer met the clinical cut-off for inattention, with the parent-reported improvements persisting for 9 months.
Games Engage: Think Kids & Teens
Horne-Moyer HL, et al. Curr Psychiatry Rep. 2014;16(12):520.
KEY POINTS
Select games based on appeal to patients & meeting goals.
Co-play can help teach social skills, problem solving, with therapist feedback.
Educate on risks/benefits (eg, sexual/violent content, parental play with children).
Camera Sensors & Fitness Trackers
http://superheroworkoutgame.com/. Accessed May 30, 2017.
Naslund JA, et al. Psychiatry Res. 2016;244:139-144.
Naslund JA, et al. Ment Health Phys Act. 2016;10:10-17.
Macias C, et al. Psychiatr Q. 2015;86(4):505-519.
Kimhy D, et al. Psychiatr Serv. 2016;67(2):240-243.
KEY POINT
Fitness games and devicesare feasible to support weight loss in patients with serious mental illness.
Discovering Devices
Medisafe on Smartwatches
Chan S. www.imedicalapps.com/2015/03/review-medisafe-app-reminders/. March 23, 2015. Accessed May 30, 2017.
Specific Phobias
Social Anxiety
Alcohol Use
PTSD
Relaxation
Virtual Reality
Virtual Reality
US$900per unit
US$5per unit
Smartwatch & Wearables Data
Activity•Activity & exercise types
•Distance traveled•Movement while sleeping
•Light exposure
Physiological•Calories burned•Step count•Heart rate•Galvanic skin response
Diagram by @jnyfav. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.
Smartphone & Watch Sensors
GPS = global positioning satellite.Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.
Sensors Mainstream Apps Potential Clinical Uses
Accelerometers can
detect person’s
movement, number of
steps
Fitness tracking Exercise, weight loss,
activity level, movement
and gait detection
Location triangulated
through GPS, phone
cell tower, and WiFi
networks
Maps, driving directions,
location-specific
photography, social
media, augmented reality
games
Activity level, movement,
wandering behaviors,
peer support, addiction
trigger avoidance
Cameras to detect light,
the person’s face, and
the person’s
movements
Security, social media
and chat, exercise,
nutrition tracking,
augmented reality
Light exposure,
photographic self-
reflection and photo
journaling, peer support
1
2
3
Smartphone & Watch Sensors (cont’d)
Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.
Sensors Mainstream AppsPotential Clinical
Uses
Cameras with depth
perception and 3D
mapping
Augmented reality
games, indoor
mapping, 3D object
scanning
Exposure to stressful
environments or
objects with response
prevention
Compass Maps, driving
directions
Movement, wandering
behaviors
Humidity Weather Environmental comfort
indicator
4
5
6
Smartphone & Watch Sensors (cont’d)
Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.
Sensors Mainstream AppsPotential Clinical
UsesTemperature of
environment
Weather Environmental comfort
indicator
Microphone Telephone calls, audio
recording, social media
and chat, voice dictation
Activity level, speech
assessment, assess
ambient noise as
environmental comfort
indicator, voice dictation
for physical impairments
Screen taps with touch
pressure intensity
Games, Secondary
controls
Activity level, cognitive
exercises
7
8
9
Smartphone & Watch Sensors (cont’d)
Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.More info in Glenn T, et al. Curr Psychiatry Rep.2014;16(12):523.
Sensors Mainstream AppsPotential Clinical
UsesHeart rate Fitness tracking Exercise, weight loss,
activity level,
biofeedback
Electrodermal activity
(skin conductance)
Stress testing Biofeedback
10
11
12
Developing Apps
Drag-and-Drop App Building
www.gocanvas.com. Accessed May 30, 2017.
Contract an External Developer
Have they previously worked with health systems?
Can they assure HIPAA and 42CFR compliance?
Can they assist with project management? How much do project changes cost?
Can they integrate w\ EHR?
…and will the company last?
Securing, Testing, & Implementing
Watch Out for Bogus Apps
Art by StockUnlimited. H/t @JohnTorousMD.Mani M, et al. JMIR Mhealth Uhealth. 2015;3(3):e82. Wilson H, et al. JMIR Mhealth Uhealth. 2016;4(3):e98. Larsen, ME, et al. PLoS One. 2016;11(4):e0152285.
700 mindfulness apps on the iTunes and Google Apps Marketplace—only 4% provided acceptable mindfulness training and education.58 apps claiming to offer sobriety assessments—“none... determined their efficacy in changing either drinking or driving behaviors.”Review of suicide apps found good safety plan apps, but none provided evidence-based support—some were even harmful (“listing lethal access to means or encouraging risky behaviour in a crisis”).
App Count
Search done April 5, 2016 for search terms in AppAnnie. Chan SR, et al. Healthcare. 2014;2(2):220-233.
Keyword Android iPhone
Depression 233 795
Anxiety 236 1185
Schizophrenia 224 32
Bipolar 245 172
Alcoholism 224 60
Perfectionism 0 0
App Count
Larsen ME, et al. JMIR Mhealth Uhealth. 2016;4(3):e96.
Volatile: “a clinically relevant app for depression [becomes] unavailable to download every 2.9 days.”
Apps Get Outdated Quickly
http://berkeleysciencereview.com/can-your-phone-cure-depression/. Accessed May 30, 2017.
Published in 2012
Half a decade ago!
None of the apps
cited are available
or updated for
years.
Industry is ahead of science & evaluation.It can take 10+ years to make new meds:
Image from www.phrma.org/sites/default/files/Drug%20Development%20Lifecycle.png.
3-6 y 6-7 y ½-2y
Consumer Apps Can’t Guarantee Privacy & Security
Huckvale K, et al. BMC Med. 2015;13:214.
×79
Consumer Apps Can’t Guarantee Privacy & Security
Huckvale K, et al. BMC Med. 2015;13:214.
Half of apps (50%, n = 35/70) included strong identifiers in transmitted information. Two-thirds of these (66%, n = 23/35, 29% of all apps) sent identifying information without encryption, including email addresses (n = 5), account login details (n = 5), full name (n = 2), or date of birth (n = 2).
KEY POINT
Inform & consent for apps, & discuss risks & benefits.
Can you text?
Image of Android Messages by https://play.google.com/store/apps/details?id=com.google.android.apps.messaging&hl=en.Drolet BC. JAMA. 2017 May 8;[Epub ahead of print].
“Texting to communicate health information is neither explicitly prohibited by HHS nor illegal in the United States.”“A combination of vigilant deidentification and maximizing available security features should maintain HIPAA compliance for text messaging.”“HIPAA compliance can...be maintained by deidentifying information before it is transmitted. Under the Safe Harbor Method, health information is no longer linked to an individual when 18 types of patient identifiers have been removed.”
2017 Federal Oversight
www.ftc.gov/tips-advice/business-center/guidance/mobile-health-apps-interactive-tool; www.fda.gov/MedicalDevices/DigitalHealth/MobileMedicalApplications/ucm255978.htm. Accessed May 30, 2017.
FTC — Federal Trade Commission
FDA — US Food & Drug Administration
Which laws apply to my health app?
www.ftc.gov/tips-advice/business-center/guidance/mobile-health-apps-interactive-tool. Accessed May 30, 2017.
Which Should You Use?
“enterprise software”nearly always a fee……because companies secure your data……and are HIPAA-compliant.
Try this test: Call them. Find their dedicated hotline for provider/practitioner support.
“consumer software”nearly always free……because the companies sell your data……despite claims of security.
Companies will reveal patient identities via the “friends you may know…” feature.
Epic, AthenaHealth, G Suite Gmail (paid)
Gmail (free), Facebook, LinkedIn, Twitter, SMS, MMS
In clinician’s office
Patient discusses symptoms
Clinician reviews history
Clinician recommends
treatment options
Patient decides on treatment
At home
Patient makes appointment with
clinic
Patient waits for appointment
Patient experiences
distress
App logs symptoms & records video
App provides initial triage &
screeningClinician
reviews app reports,
dashboard
App provides education
Using Apps in Clinical Workflows
Diagram by @jnyfav. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.
Sharing
Ease of Use
Efficacy
Privacy and Safety
Ground
PRIVACY & SAFETY: Privacy policy, Data collected, Protection/de-identification of data, Opt out of data collection, Delete data, Physical location of data, Security & encryption, HIPAA & CFR
GROUND level: Business model, Developer, Cost / In-App Purchases / Free, Advertising model, OS platform, Date last updated
EVIDENCE: Functionality vs Claimed functionality, Clinical studies & data evidence, feedback from users to support claims (app stores, review sites), and appearance of reasonable value
5
4
3
2
1
EASE OF USE: Easy to access, Customizable, Offline and limited Internet functionality, Platform availability, Accessibility for those with impaired vision or other disabilities
INTEROPERABILITY & DATA SHARING: Can it share data with electronic health records; can data be printed, exported, or downloaded; can share data with other user data tools (eg, through Apple HealthKit, Google Fit)
Ask yourself these questions about the app — from 1 to 5 — before “prescribing.”
Based on: American Psychiatric Association. App Evaluation Model. www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model. Accessed May 30, 2017. Diagram by @jnyfav. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.
Know How to Track & Block Permissions
https://play.google.com/store/apps/details?id=com.humberto.flashlight. Accessed May 30, 2017.
vs
Know How to Track & Block Permissions
Raggett D. July 2014. www.w3.org/2014/05/wp-trust-permissions/Overview.html. Accessed May 30, 2015.