SummarySan Mateo Medical Center distributed mobile phones with customized disease management software to young asthma patients, allowing them to communicate with and receive real-time feedback from providers on at least a daily basis. The communication focuses on how to better manage asthma on an ongoing basis, with the goal of reducing exacerbations that might lead to costly acute episodes. The initiative enhanced compliance with the daily diary and with medication regimens, which, in turn, led to better patient outcomes, less use of rescue medications, and fewer emergency department visits and missed school days. The initiative was suspended after grant funding ended in 2009.Moderate: The evidence consists of a small, 8-month pilot test conducted at the San Mateo Medical Center that provides before and after comparisons on key measures.
Developing OrganizationsBeWell Mobile Technology, Inc.; San Mateo Medical Center
Date First Implemented2005
Age > Adolescent (13-18 years); Child (6-12 years); Vulnerable Populations > Children
Problem AddressedSelf-management is a critical component of care for 133 million patients who live with at least one chronic illness,1 but many patients are ill-equipped to manage their conditions without effective self-management tools. This lack of effective self-management support leads to costly inpatient admissions and emergency department (ED) visits.
- Lack of self-management support: Chronically ill patients need regular feedback to manage their conditions effectively. In the absence of such feedback, patients may not promptly or appropriately react when their health is at risk and may find it difficult to remain motivated with regard to self-care activities. Most chronically ill patients would benefit from real-time feedback regarding their current and developing health status. Existing monitoring devices can be costly and cumbersome, especially for patients with multiple chronic illnesses who may require a specialized device for each condition.
- Leading to costly admissions and ED visits: Lack of self-management support can lead to emergent situations and acute exacerbations that frequently require costly inpatient admissions and/or ED visits. In fact, much of the 75 percent of overall health care costs attributable to chronic disease care1 could be avoided through better management of these conditions. At least one-half of hospital admissions for primary care–sensitive conditions could potentially be avoided through better management of the patient's condition in the outpatient setting.2 This figure may be higher for certain minorities, such as African Americans and Hispanics, who have higher preventable hospitalization rates for major chronic conditions than do White individuals.3
Description of the Innovative ActivityIn a 2-year pilot test of mobile phone disease management application software developed by BeWell Mobile Technology, children and teens with severe persistent asthma sent health status measures to their providers at San Mateo Medical Center on a daily (or more frequent) basis and received real-time feedback to help manage their condition. Key aspects of the communication process are outlined below:
- At least daily patient data input: Fifty bilingual teens and adolescents cared for by physicians at three San Mateo Medical Center clinic sites recorded their symptoms on a mobile phone at least once a day by answering 20 questions authorized by clinicians. The questions prompted patients to input data related to disease-specific elements of their care plan. The application uses an "electronic diary" format that allows users to record momentary assessments on an ongoing basis. Information requested includes biometric, symptomatic, behavioral, and environmental details related to the condition and any comorbidities. The software minimizes keystrokes via use of menu options or minimal numerical input, allowing patients to be "in and out" in approximately 30 seconds.
- Ongoing caregiver monitoring: An asthma care coordinator received and monitored patient information and reports, including red flags for abnormal conditions.
- Real-time feedback based on care algorithm: The disease management platform allowed the coordinator to provide automated or personalized feedback, based on a physician-authorized algorithm, to patients as appropriate. Patients viewed the information from a menu on the phone, with key reports and feedback automatically generated when the entries were recorded. Patients and providers could also view trend data in graphic form. Key types of feedback included the following:
- Reward and encouragement: Patients with stable health status received a response that congratulated them on their efforts and encouraged their continued health maintenance.
- Minor modifications: When indicated, patients received a near-instant message on suggested changes in their daily action plan based on their current status and the agreed-on regimen.
- Reminders: As appropriate, patients received reminders to refill prescriptions, reorder medical supplies, fulfill daily health regimen requirements, and schedule physician appointments or diagnostic tests.
- Quick interventions in urgent/emergent situations: If the submitted data suggested a risk to the patient's health status, an "exception report" was automatically generated, alerting both the patient and the provider to appropriate next steps. If an emergent situation was suspected, the coordinator typically called the patient directly and mobilized any additional needed services.
- Ongoing evaluation: Data were collected in a secure network storage site to allow for the development of trend reports.
Context of the InnovationThe San Mateo Medical Center is a public hospital with 9 outpatient primary care clinics serving 50,000 patients who make more than 220,000 visits annually. San Mateo cares for more than 1,000 children and teenagers with severe persistent asthma, most of whom live in poverty and are bilingual. Historically, these patients received uncoordinated care with little between-visit monitoring, causing high use of the ED and clinics when symptoms exacerbated. The organization's leaders wanted to improve care for asthma patients and reduce unscheduled physician visits, ED use, and hospitalizations by identifying innovative ways to engage patients outside the clinic. San Mateo's clinicians, moreover, believed that having regular access to patient-reported data was the key to effective monitoring and their ability to provide focused, timely interventions to prevent acute exacerbations. Before learning about the mobile phone application, however, San Mateo's leaders believed that potential quality improvement strategies were somewhat limited due to the lack of high-quality, affordable tools for facilitating such communication. The California HealthCare Foundation alerted San Mateo leaders to the BeWell Mobile Technology system and provided a grant, allowing San Mateo to purchase the application and to fund cell phone service and the salary of an asthma care coordinator for 1 year.
ResultsAn 8-month pilot test conducted at the San Mateo Medical Center found that the initiative enhanced compliance with the daily diary and with medication regimens, which, in turn, led to better patient outcomes, less use of rescue medications, and fewer ED visits and missed school days. More specific results from the study, which involved 50 children and adolescents with severe and persistent asthma covered by Medicaid, include the following:
Moderate: The evidence consists of a small, 8-month pilot test conducted at the San Mateo Medical Center that provides before and after comparisons on key measures.
- Improved compliance with drug regimens: Compliance with prescribed drug regimens more than doubled, from approximately 40 percent to more than 85 percent.
- Strong adherence to diary regimen: Ninety-five percent of patients complied with the daily diary regimen throughout the 8-month trial period, completing an average of 0.87 momentary assessments per day. These figures compare favorably to the typical 30 to 40 percent "best-practice" reporting rates achieved through use of paper diary logs.4
- Increased average peak flow: Average peak flow assessments increased by 19 liters per minute per patient during the 8-month trial period.
- Less use of rescue medications: Use of rescue medications fell by 53 percent during the trial period.
- Fewer ED visits and missed school days: During the 8-month pilot, patients 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.
- High satisfaction: User satisfaction with both the phone and the application were high (at roughly 95 percent each). Patients generally favored the mobile phone diary over a paper diary, finding it more convenient and fun to use.
Planning and Development ProcessImplementation of the program included the following key steps:
- Application design and physician signoff: BeWell Mobile Technology designed the daily action plan for patients based on care requirements and formulated them into an "electronic diary" that included preformatted protocols, predefined questions and responses, and algorithms for care; information was provided in Spanish and English to accommodate San Mateo's patients. Clinicians determined how often they wanted patients to input information and authorized use of the regimen with patients.
- Initiating relationship with mobile phone provider: San Mateo contacted mobile phone providers and selected Cingular/AT&T. San Mateo purchased mobile phones and related data services for 1 year. BeWell Mobile Disease Management applications are compatible with virtually all cell phone models; 86 percent of individuals aged 7 to 26 years already own a personal cell phone.
- Creating asthma care program: Program leaders designed an asthma care program with the BeWell Mobile application as a centerpiece. Asthma care algorithms were implemented, with specialized forms for providers to use when tracking care. San Mateo hired an asthma coordinator/educator to oversee the program and provide guidance and education to patients.
- Creating computer interface: BeWell worked with DocSite, the developer of San Mateo's patient registry technology, to create an interface so that information coming from the mobile phones could be uploaded to the registry.
- Patient recruitment and setup: San Mateo Medical Center clinical teams contacted eligible patients based on their diagnosis and offered them the option to participate. Interested patients received a mobile phone preloaded with the software.
- Patient training: An asthma care coordinator briefly instructed patients how to download and open the appropriate medical management application. Using the application is largely intuitive, as patients need only scroll through and select correct answers by using the two "soft keys" on the mobile phone keypad rather than typing in words.
Resources Used and Skills Needed
- Staffing: One full-time coordinator/case manager can monitor many patients. The BeWell system prioritizes information for providers based on patient needs, thus improving workflow efficiency and enabling the caregiver to handle a larger caseload. Initial setup requires minimal time from information technology staff, primarily to assure seamless integration with the existing electronic medical record and disease registries.
- Costs: Pricing includes three components: software application licensing and setup, a patient enrollment and setup fee, and a recurring monthly subscription fee. Pricing varies by scale of implementation and term commitments.
Funding SourcesCalifornia Healthcare Foundation
The pilot test was funded by California HealthCare Foundation. The funding for the program has ended.
Getting Started with This Innovation
- Maximize compatibility: Ensure that applications are compatible with the maximum number of existing mobile phone models. If patients have their own mobile phones, ensure that their service is compatible so that data and applications can be transported; basic data capabilities are required.
- Set up systems to minimize abuse: If providing phones to patients and subsidizing service contracts, ensure that mobile phones are set up such that service cannot be abused—for example, used for out-of-area phone calls.
- Develop target population: Determine which patient populations are best able to use this type of technology. Poor candidates include those not physically able to use cell phones and those who are mentally impaired.
- Prequalify patients: Do not force patients who do not like to use mobile phones or computers to participate. Ensure that patients understand the responsibilities, obligations, and opportunities associated with participation.
- Involve clinicians to ensure buy-in: Engage as many clinicians as possible in the application setup and care management program development, including physicians, nurses, and case managers. This step helps to ensure their active support and facilitates agreement on a common set of protocols.
- Design program to enhance workflow: Determine and define how the new process will be integrated into the larger system of care. The program should be designed to enhance the efficiency and productivity of clinicians, helping them do their job better and more quickly.
- Integrate into existing information systems: The data gathered should be integrated into existing information systems and warehoused for later reference.
Sustaining This Innovation
- Pilot test with small group, then expand: Implement the new technology with a small group and then expand to a larger population. The initial test should gauge how easy the application is for patients and clinicians to use.
- Refine application over time, based on feedback: The application should be as interactive as possible, which is critical to motivating changes in patient behavior.
- Secure ongoing funding: Find an ongoing source of funding to cover the costs of the applications and asthma care coordinator. San Mateo had to temporarily suspend the program when its grant funding ran out.
Spreading This InnovationKaiser Permanente has implemented the BeWell Mobile Diabetes Assistant application with 84 adults diagnosed with type 1 or type 2 diabetes and poor glycemic control. Results show meaningful improvements in blood glucose levels. In addition, the University of California at San Francisco and Kaiser Permanente Division of Research have each used the BeWell Mobile platform and diary applications for patient-recorded outcomes in primary research.
Additional ConsiderationsBeWell has also developed applications for diabetes, hypertension, heart disease, medication adherence, and physical activity. The communications (including content and frequency of interaction) can be tailored to fit the needs and desires of a particular provider group and the specific requirements of the target population.
References/Related ArticlesAdler R. Health Care Unplugged: the Evolving Role of Wireless Technology. Oakland: California HealthCare Foundation; November 2007.
Boland P. Managing Chronic Disease through Mobile Persuasion. Palo Alto: Stanford Captology Media; 2007:45-52.
Boland P. The emerging role of cell phone technology in ambulatory care. J Ambul Care Manage. 2007;30(2):126-33. [PubMed]
Boland P. Better health well in hand. Cell phones have the capacity to more frequently and efficiently connect chronically ill patients with caregivers. Healthcare Inform. 2006;23(4):56-7. [PubMed]
Sanderson C, Dixon J. Conditions for which onset or hospital admission is potentially preventable by timely and effective ambulatory care. J Health Serv Res Policy. 2000;5(4):222-30. [PubMed]
Laditka JN, Laditka SB. Race, ethnicity and hospitalization for six chronic ambulatory care sensitive conditions in the USA. Ethn Health. 2006;11(3):247-63. [PubMed]
Boland P. The emerging role of cell phone technology in ambulatory care. J Ambul Care Manage. 2007;30(2):126-33. [PubMed]
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Original publication: April 18, 2008.
Original publication indicates the date the profile was first posted to the Innovations Exchange.
Last updated: January 29, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.
Date verified by innovator: January 24, 2014.
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