User:Kevinlmcmahon

Mobile Community Health Network

Introduction --- Genesis of the idea occurred in 2001. Initially a core dependency built into the general concept was a specialized piece of celluar transmission hardware that would facilitate the management and transmission of medical devices and the data stored within. For example, a blood glucose meter.

Educating people about their health in relation to their behavior became a key enhancement of the concept circa 2004. The better the data (timely and accurate) the better the insight and thus the better the ability to deliver relevant education in a feedback loop design. Given the completeness and timeliness of the data provided by patients who used the specialized hardware, this education loop worked extremely well in its several field trials (ie - AT&T employee diabetes pilot).

Even in 2001 when the concept was conceived it was clear that mobile phones had potential. However, due to the manual nature of the phone and dependency on the patient to type data and send manually this was always viewed as an inferior approach vs. the telemetric aspect of the specialized device.

In 2007 it became clear that the entire industry was reserved in its willingness to pay for these education focused services including any form of remote patient monitoring. Also, it became clear that having a core dependency on a specialized piece of hardware that would have to be issued to the patient in addition to the cost were barriers to large scale education and feedback delivery.

Various discussions were held and an initial design was sketched which attempted to mitigate the deficiencies of the mobile phone only approach. In addition, due to our historically rural focused experience we knew that even a mobile only dependency would be the Achilles heal.

Childhood Obesity Straw Man --- Finally in 2008 the concept was completed based on a target intervention designed to stem the tide of childhood obesity.

It is generally understood among experts in health that only addressing the child with obesity is a failed strategy. Therefore, most interventions focus on educating the parent(s) of the child. However, this intervention design has only seen limited success for at least two reasons; 1) it depends on the family making multiple visits to a facility offering the education and motivation; and 2) for similar reasons why only addressing the child is flawed, only addressing the immediate family also ignores the daily influences of extended family, co-workers and community which enabled the obese child in the first place.

Continuing this notion beyond the community, to the State level for example, clearly doesn't make sense due to the lack of opportunities for immediate and personalized influences on the family and the environment. Therefore, the idea centered on community based interventions as the appropriate scope going beyond traditional physician-directed and patient-specific telehealth dogma.

Next, we considered the pros and cons of the physician-directed model in light of the early successes discovered during several patient self-care diabetes telehealth clinical trials. Given that more than 30% of people with diagnosed type 2 diabetes are not even getting at least one hemoglobin A1c test per year (the ADA standard is at least one HbA1c test every six months) we saw an opportunity to test our community telehealth intervention design by reversing the flow of patient data.

What if we could get some of those 30% of people to understand the importance of the HbA1c and to make sure they were empowered to demand the A1c at each of the physician appointments and to schedule and attend them every 6 months in line with the standard of care?

Funding --- About the same time we had arrived at this novel approach, we discovered the HRSA/OAT telehealth grant program and searched for a partner to implement and test these concepts. Our long time partner had been Driscoll Children's Hospital and eventually it was decided that we would partner with Driscoll Children's Health Plan instead. The health plan had experience with a childhood obesity program, a charter for providing disease management to its members and a growing risk with diabetes in pregnancy case load.

In Spring of 2009 we submitted our proposal to the HRSA/OAT program and eventually received a competitive award. (HRSA/OAT Grant Number: H2AIT16625-02-02)

Year 1 Design --- The year one charter had three main tiers of service: 1) establish an anonymous registry of 250 people in the seven county area with a shared interest in health; 2) identify 50 children and 100 adults with a family relation to at least one person with diagnosed type 2 diabetes; and, 3) recruit, manage and support 18 health plan members with diagnosed diabetes in pregnancy using a previously successful model of home telehealth including drop-shipped care kits incorporating the GlucoMON-ADMS telehealth device and registered blood glucose meter. This protocol was previously vetted in children with type 1 diabetes and a modified version addressing adults with type 2 diabetes.

Rural Forms --- A major departure from the original design which occurred during year 1 with approval for the change from the HRSA/OAT Program Officer was to eliminate the USPS mail feature. This component was thought to be critical in at least the early stages of the project to ensure that we were able to engage the rural South Texas population. Based on prior work in the area, lack of Internet access is pervasive. While mobile phones are prevalent, not all people have a text messaging plan nor would they be willing to take the risk that enrolling in the program might subject them to some unknown and unfamiliar expense.

Retooling the program to address this change took time and unfortunately made it impossible to test the idea that telehealth education and data collection from the home might be viable without involving electronic data transmission.

Emphasis on Mobile --- While mobile two-way interactions were originally planned, there were multiple methods of enrollment attempted. Each of these methods have their own pros and cons including SMS sign-up (text HEALTHY to 25827), website enrollment followed by manual addition to the mobile gateway database and forms collection data entry which was subsequently added manually to the mobile gateway database in the event that the form included a mobile #. Finally, we integrated data provided by DCHP's multiple patient records systems into a separate engagement database that allowed us to attempt large scale enrollment of patient families with known diagnosis of asthma. Time and expense for each of these methods are very different and learning the intricacies of each method were not originally accounted for as these new ideas were discovered along the way.

Impact on System Design due to Community Scale in excess of original design ---

Evaluation Framework

Even our evaluators for the program guided us to disregard data collection from patients under active care of a physician as simply duplicating health care. The real opportunity was to discover those individuals at risk or previously diagnosed and to get them back into the care of a physician.

Year 1 Results --- Tier 1 = Target Exceeded. 6,167 people enrolled in the registry within 9 months of launch. Tier 2 = Target Exceeded. Tier 3 = Target Exceeded. Twenty-four (24) patients were recruited including telephonic enrollment and confirmation and 24 care kits prepared and shipped to the patient's home address. However, only 3 patients went live on the system due to apathy including documented recommendations by many physicians that their patients should not participate or did not need to check blood sugar. In contrast, results from a similar pilot in the UK, led by a physician and his staff, resulted in a very different set of outcomes. For starters, patients were highly satisfied (http://dl.dropbox.com/u/29122412/easySHARE%20Testimonials%20v2.pdf) and office visits were reduced by 50% without any impact on quality of care (http://www.advancingqualityalliance.nhs.uk/document_uploads/Case_Studies/Bob%20Young%20RIF%20End%20of%20Project%20Monitoring%20Form%20Salford%20EasyShare.pdf).

Similar Efforts --- Text4Baby - launched Feb 2010 - six weeks after Healthy Families of South Texas Text4Baby HRSA Sponsored Evaluation Program Multiple Offers to Collaborate

Year 1 Changes in Telehealth Landscape ---

Year 1 Lessons Learned ---In spite of success elsewhere, direct to patient recruiting for the diabetes in pregnancy segment in South Texas is not a viable approach.

Year 2 Design ---Eliminated Tier 3 until physician support could be reasonably assured ---Continue with Tier 1 and Tier 2 ---Expand into Childhood Asthma and serve 250 patients based on prior experience via Children's Medical Center of Dallas pilot program (no device issues - leverage family's existing cell phone ---Focus on SMS for universal adoption vs. smart phone dependency of most alternative mobile asthma programs

Year 2 Results --- Over 30,000 enrolled in Tier 1 NNNN enrolled in diabetes NNN (several hundred as of July 2011) enrolled in asthma

Similar Efforts --- Text4Baby (http://text4baby.org) Text4Diabetes alternative mobile phone enabled asthma program

Year 2 Changes in Telehealth Landscape --- Texas SB293 signed into law

Year 2 Lessons Learned --- Year 3 not practical due to program constraints which do not allow for frequent testing of new concepts

Translation to Other Community Initiatives --- http://sierrahub.blogspot.com

HHS Recommendations http://www.hhs.gov/open/initiatives/mhealth/recommendations.html Next phase will reorganize this wiki along the lines of the recommendations and guidelines in the above

Message Sent to Todd Park via Vince Kuraitis via LinkedIn on 9/22/11

Dear Todd,

I just read your Text4Health Task Force summary of recommendations regarding health text messaging services.

http://www.hhs.gov/open/initiatives/mhealth/recommendations.html

My team has just completed a 2 year HRSA/OAT sponsored health text messaging project which we launched to the public on Jan 1, 2010 initially focusing on diabetes and in year 2 expanded to address childhood asthma.

HRSA/OAT Grant Number: H2AIT16625-02-02

While our program in partnership with Driscoll Children's Health Plan was constructed as a mobile community health network, the bulk of our participants were localized in South Texas. However, the community was available to anyone free of charge nationwide. Within the first year of operations, the community included over 30,000 participants who received education including profile establishment and HEDIS responses which updated their PHR.

Within my team's quarterly reports I have consistently offered to connect the dots between our program and the Text4Baby program but without acknowledgement.

I hope you will contact me to discuss this further. It would be a shame for all of this experience to be lost and/or funds spent to replicate what has already been attempted toward health care delivery modernization.

Regards,

Kevin L McMahon http://kevinlmcmahon.com Project conducted by Healthimo under contract to Driscoll Children's Health Plan Original design by Kevin L McMahon originating in 2004 as part of a two-way text messaging education service called Virtual CDE.