eHealth, mHealth, and Telehealth

 eHealth- use of technology to transcend geographical distance to promote good health

 mHealth- use of mobile devices (ex: phones, tablets) to promote good health
 telehealth- collection of means or methods for enhancing healthcare, public health, and
health education delivery and support using telecommunications technology
o includes:
 public health alerts regarding infectious disease updates
 online consumer educational references
 apps and devices
 healthcare through a provider
 telemedicine
o subset of telehealth
o offering clinical services to patients at a distances, usually through the use of
teleconference exams, share diagnostic data, phone and/or computer-mediated
conversations
o examples:
 Video Visit with a provider
 Remote Monitoring (blood sugars, heart rhythms)
 Provider to Provider patient consultations
 Stroke Carts/specialty Care
 ICU/ER outsourcing
 Remote Robotic surgery
o Pros:
 Expanded Access (mobility, geographic isolation, specialty care)
 Cost and Efficiency of Care
 Reduce unnecessary ER visits
 Patient care requires less office support
 Reduces no shows and late arrivals, increases compliance
 Convenience
 Average face-to-face appointment in clinic consumes 2 hours of
patient’s time
 Average video visit less than 20 minute (typically 7-10 minutes)
o Cons:
 Requires technology and training
 Stroke Cart
 Secure Video chat
 Breakdown in Continuity of Care
 Provider who doesn't know the patient is prescribing medications
 Sometimes Need In-Person Exam
 Restrictive policies
 Regulations
 Reimbursement lag
 mHealth example
 o apple heart study demonstrates ability of wearable technology to detect atrial
fibrillation
 Stanford virtual research study with more than 400,000 participants
 Wearable technology can safely identify heart rate irregularities that
subsequent testing confirmed to be atrial fibrillation
 Atrial fibrillation is a leading cause of stroke and hospitalizations
in the U.S.
 Used Apple Watch
o .5% of participants receive irregular pulse notification
o Pulse detection algorithm has a 71% predictive value
o 84% of the time, participants who receive irregular pulse notifications were
found to be in atrial fibrillation at time of notification
o 34% of participants who receive irregular pulse notifications and followed up by
using ECG path over a week later were found to have atrial fibrillation
o 57% of participants who received irregular pulse notifications sought medical
attention
o Results of the Apple Heart Study show potential role that innovative digital
technology can play in creating more predictive health care
 Health Information Acquisition Model- People are motivated to seek info when…
o Attention is called to issue/concern
o Perceive they are not well informed
o Believe they will find trustworthy, useful info
 Theory of Motivated Information Management (TMIM)-Similar to health info
acquisition model, but also considers…
o Coping confidence: Am I ready to deal with what I might discover?
o How the info is conveyed: Source matters, and it affects belief in information
 Integrative Model of Online Health Information Seeking: Similar to other models, but
also/especially considers…
o Social structures and inequities manifest in individual differences
o These differences influence how able and motivated people are to seek eHealth
info (digital divide)
 Online health info
o Advantages
 Quantity of info
 Availability of info (24/7)
 Social support
o Disadvantages
 Unreliable info
 Conflicting info (confusion)
 Overwhelming info
 Digital divide
 Social network theory
 o We experience strong ties with people whose networks overlap ours a lot, and
weak ties with people whose social networks do not overlap much with our own
o Strong ties are good for stability, loyalty, comfort
o Weak ties help us avoid an insular perspective, expose us to new information,
experience different things, can become more important in certain situations
 Information Sufficiency Threshold: The amount of information a person needs to feel
capable of coping with and understanding a threat (or health issue)
 Information seeking vs. scanning: Active search for info vs. info that comes up in
conversation or via media (and sticks)
m-Health for weight control
 M-Health interventions:
o Texting for weight control
o App-based weight control programs
o Combo programs that mix these tech platforms and/or in person elements
 Text messaging
o All cellphones
o Pew Research Center estimates 97% of adults have cell phones
o Has potential to reach most US adults
 Compare with penetration of internet use
 Compare with access to wearables
 Some estimate the digital divide is even wider in other countries
 Similarly high proportion have cell phones and use for texting
 Even lower proportion do not have access to internet or other
forms of eHealth technology
 TEXT4DIET PILOT
o Randomized overweight & obese adults to a weight loss SMS intervention or
control
o Intervention: 3-5 logic driven personal SMS/day for 4 months and brief monthly
phone call from health coach for 4 months
o Participants given printed binder with nutrition topics and behavioral strategies
to supplement the phone-based messaging and a food exercise journal to
support self-monitoring
 Intervention topics
o Goal setting and self-monitoring
o Portion control, strategies for eating out
o Physical activity, strength training
o Overcoming barriers, staying motivated
o Weekly instructions
 Weight
 Write down food/exercise goals
 Set goals for 500 kcal/day reduction strategies covered that week
 Tailored text messages
o Choose number/timing of messages
 o Half of messages requested a reply, with others providing tips, suggestions, and
positive reinforcement or encouragement for improved behaviors
o Type and content of messages sent changed each day
 Comparison group
o Received same baseline dietary assessment as intervention group and was
mailed one to two pages of print materials once a month for 4 months with tips
and suggestions about weight control
o Not the same information provided to intervention
 Participants
o Inclusion criteria
 25-55
 Overweight/obese
 No medications that cause weight gain
 Using mobile phone for texts
o 65 adults enrolled and followed over 16 weeks
 80% women
 75% white
 17% African American
 Intervention lost more weight than comparison group
 Adherence and satisfaction
o Adherence went down over time
o Satisfaction with intervention was high (92%) would recommend
o Open-ended question responses about user likes
 Next generation: TEXT4DIET study
o RCT
o 12 month intervention duration
o Expanded content covered
 Sugar sweetened beverages
 Sedentary behaviors
 Physical activity
o Expanded message bank for extended duration and content
o Pedometers provided
o Baseline assessment to craft eating behavior topic messages
o Digital scale given
 Text content in TEXT4DIET
o Tips, facts, motivation, messages requesting answers to knowledge questions or
self-monitoring data on weight and steps (SMS)
o MMS used to send pictures demonstrating portion sizes and other content
o Personalized feedback on weight and steps
o Algorithm selected monthly eating behavior topic to focus on
o Monthly e-newsletters
o Website
o Self-weight on digital scale
 More of a multi-component intervention than purely a text intervention
 Self-monitoring diminished over time
 Weight loss
o No significant differences over time
o Most WL occurred during first 6 months
 More in intervention than controls
 Monthly phone calls used in pilot may have enhanced the effects of SMS but not used
here
 Extension to 12 months required motivation over a longer time
 Habituation to daily SMS since the majority of WL occurred during first 6 months
 12-month measurement took place between thanksgiving and new years so holiday
weight gain
 Engaged study
o RCT
o Examined 2 abbreviated versions of DPP
o 6 and 12 month weight losses
o Goal directed
o Self-monitoring
o Financial incentive
o STND/TECH WL greater than SELF at 3 and 6 months
o STND/TECH tracked more often than SELF
o TECH tracked more than STND
 Conclusions
o Everyone lost weight over time but abbreviated DPP approach with group
sessions produced greater weight loss than a totally digital approach at least for
first 6 months while coaching and groups were in place
o Tracked time for coaching and found it took less than 4 hours to deliver
abbreviated DPP
o Intensive interventionist directed approach with in person sessions, walking
groups and phone calls did not differ in WL from a full self-guided approach by
12 months
 opt in conclusions
o Optimal digital treatment package within their $500 cost parameter
o