Mobile Health Holds Promise and Challenges for Managing Heart Disease
When Johannes Gutenberg unveiled his movable-type printing press in 1439, it promised to open up a new world of knowledge to the masses, but it took several generations for literacy levels to rise before that promise could be realized.
A similar disruption is taking place now, as digital technologies – particularly mobile platforms – begin to pervade every aspect of our daily lives. In health care, the promise is especially seductive: technology can make care safer, cheaper and more effective, while empowering patients to take greater control of and responsibility for their own health. But this shift won’t happen overnight; it will require re-education of patients and clinicians, and thoughtful planning and careful implementation to make it happen safely, in a way that benefits those who need it most.
Text Messaging for Medication Adherence
While working as a nurse practitioner in a cardiology clinic in the early 2000s, Park was struck by the number of coronary heart disease patients who went on to have heart attacks, even after receiving angioplasty and stents. The problem, she says, was that patients often delayed starting essential antiplatelet medication, either because they didn’t understand the importance of beginning therapy immediately, or because of insurance-related barriers, putting them at risk.
“Those kinds of patients struck me the hardest because it was such a preventable consequence,” Park says.
In 2009 she returned to the School to pursue a doctorate, hoping to develop practical tools to help patients like hers manage their disease more effectively at home.
“I was trying to come up with a creative way to have patients engage in their own health,” she says. She looked to the possibilities offered by mobile technologies that could connect patients interactively with both information and guidance, and developed a text-messaging intervention based on her observations.
Her dissertation project was a randomized controlled trial comparing 30-day medication adherence rates among coronary heart disease patients. She found that the groups of patients who received customized text messages (one group received education only and another received both education and medication reminders) were more likely to take their medications on time and in the correct dose than those who received no text messages.
Park presented her work at the 2013 meeting of the American Heart Association, which gave her its prestigious Martha N. Hill New Investigator Award to continue her work. A three-year KL2 award from the National Institutes of Health (NIH) and UCSF, coupled with a four-year Nursing Research Initiative Award from the US Department of Veterans Affairs, is allowing her to plan a larger-scale study of texting and other mobile-application-based interventions in a group of veterans with coronary heart disease who need to take blood-thinning medication after a heart attack or stent placement.
Can Mobile Apps Help Change Behavior?
Adding new and effective tools to the medication-adherence arsenal is a potentially important development in improving outcomes for people with coronary heart disease. Research suggests that more than half of these patients don’t take their medication as prescribed. Park says, “We need to motivate them, because there are critical consequences if you don’t take follow therapy. It can be life-threatening.”
“What we’re really trying to change is behavior, which is a challenge,” says Dean Emerita of the UC San Francisco School of Nursing Kathleen Dracup, a nationally recognized leader in cardiovascular nursing and research, who has been mentoring Park in her work. “Patients only see their health care providers for a very brief time, so if there’s any way we can invade their more private space, if you will, we can better help them take care of themselves.”
Because they are becoming ubiquitous – always on, always with us – mobile devices and applications may be particularly well suited to being those “space invaders.” They are like companionable coaches, gently reminding us to get more exercise, eat better or take our medication on time, and keeping us honest by recording the data.
Of course, any application is only helpful if patients actually use it, so getting the user experience right will be crucial to the success of any technology-based intervention.
For the first phase of her new study, Park is conducting focus groups to find out what coronary heart disease patients want in a mobile health application. “People came up with a list of things they’d be interested in receiving, like recipes and heart-healthy tips for living, so we’re trying to figure out what kinds of interventions we’re going to apply in the randomized clinical trial,” she says.
Keeping It Simple
Park is cautious, however, about trying to do too much with mobile applications at this point. The majority of patients with coronary heart disease are middle-aged or older – a group that may not be comfortable with more complicated applications, or with the newer devices that may be required to run them. In her dissertation study, she says, only a small percentage had technical difficulty, although she did have to teach some patients how to use text messaging. “They did very well,” she says. “My hypothesis is that in this population, text messages may be enough to give them a reminder, and that sense of engagement with someone who cares about them. It’s a powerful and simple way to engage older patients.”
Dracup concurs. “Research shows that as people age, it becomes a little more difficult to grasp newer and more sophisticated technologies. We have to figure out ways to reach people who are relatively new to using [mobile technology] or are using old devices.”
Text messaging would seem to be a good bridge. The technology has been around long enough that most people have used it (a 2010 Pew Research Center study found that 72 percent of adult cellphone users in the US have texted), and it remains relatively simple, requiring only basic devices. It has also become relatively inexpensive; most major cellphone plans now include texts with voice service in their monthly fees.
New Technologies, New Challenges
The simplicity of text messaging is a plus right now, but as digital-native generations begin to develop the chronic conditions that often accompany aging, they may expect to use more sophisticated applications to help manage their health, which will bring new challenges to the health care environment.
The health care and technology industries will need to continue to find ways to collaborate adaptively to address health care’s privacy and data security concerns while taking advantage of the speed and flexibility that are chief assets of many technology companies.
The speed of technological change presents a special challenge in the context of health care research. Dracup says, “By the time people do the pilot testing and get funding for a big clinical trial, you’re usually 5 to 10 years down the road [from when the study was designed].” In technology terms, that’s several generations, which means researchers are often going to be testing interventions based on obsolete technology.
Creating Community for Health
Despite the challenges, one of mobile technology’s strengths – encouraging people to create and tap into community – remains one of its biggest potential benefits in terms of improving health outcomes. Researchers are just beginning to examine how engagement with supportive communities can promote positive health behaviors, like exercise or smoking cessation. Moreover, real-time tracking technology opens the way not only to easier sharing of data with caregivers and clinicians, but also for innovative modalities, such as gamification, to motivate people to engage in their own care.
Creating engagement is one of the key aims of Park’s study. She plans to utilize the VA’s existing Health Insurance Portability and Accountability Act (HIPAA)-compliant text messaging platform, and will be among the first to test its use among patients with cardiovascular disease. “We want to inform the VA on a large scale how to engage with their patients,” she says. “Text messaging may be enough to give them a sense of engagement and that someone who cares about you is watching.”