One of  the most fascinating speakers was Dr. Eddy Lang, who gave a most insightful key note entitled: Information Science in the Evidence Based Era: Meeting the Perceived and Unperceived needs of Evidence Consumers. He is an eminent academic emergency physician and researcher who is passionately interested in Evidence-Based Medicine (EBM) and Knowledge Translation (KT).

Some of the gems from his talk included four scenarios of when evidence would be needed in clinical practice and what the gaps might be.

• Treating a 25 year old female in the emergency ward with anxiety attack and symptos of a pulmonary embolism. Should you recommend a CAT scan or not? A CAT scan delivers a high amount of unnecessary radiation. To make a decision, the physician needs access to a validated decision tool – the pulmonary embolism rule out criteria – which may establish that in fact, the embolism is not the primary problem and preempt unnecessary radiation exposure. Physicians lack the the skills to find this information at the point of need during critical decision points.
• A resident presenting on atrial fibrillation excluded key onging trials within Calgary – found in the Clinical Trials.gov site
• In developing clinical tools such as orders sets, health professionals lack embedded decision support for levels of evidence.

Drawing on Alison Brettle’s study, Dr. Lang identified 4 models of clinical librarian integration that can help physicians access information at the point of need:

• Questions and Answers
• Questions and Answers + Critical appraisal
• Outreach: proactively engaging and embedding librarians
• Outreach + Critical appraisal + Synthesis

Credits

“Evidence stamp” from http://clinicigo.wordpress.com/home/

“Primary care is the first point of contact a person has with the health system – the point where people receive care for most of their everyday health needs. Primary care is the first point of contact a person has with the health system – the point where people receive care for most of their everyday health needs. Primary care is typically provided by family physicians, and by nurses, dietitians, mental health professionals, pharmacists, therapists, and others” (What is primary care?)

Divisions of Family Practice

Under the auspices of the General Practice Service Committee, the Divisions of Family Practice was designed to both improve patient care and address family doctors’  influence on health care and professional satisfaction.  Family doctors in a community organize themselves into a non-profit to work towards common health care goals. They are able to receive funding towards their initiatives.

I learned about this initiative when I listened to a presentation made to seniors by the White Rock South Surrey Division.  One of the first of three to be established in BC, this division seeks to improve:

• population health
• the patient/provider experience
• system sustainability

I was impressed that this division of 73 members has 3 staff members. Their programs promote enhanced hospital care, local citizens’ access to a family doctor (through the attachment initiative), recruitment of additional doctors to ease the shortage and continuing education programs for doctors.

Their key initiative is the Primary Care Access Clinic which supports unattached patients (lacking a family doctor) who require care upon discharge from Peace Arch Hospital. The clinic is staffed by a multidisciplinary team which includes nurse practitioners, mental health care staff and social workers and home health workers who can refer patients to needed services and monitor complex cases.

When I mentioned this interesting model to a pharmacist colleague, he had an interesting comment. He said that progressive practices will usually recognize the need to have nurse practioners, social workers…but for some reason, they don’t seem to see the need for a pharmacist. This is partly because pharmacists are often perceived as retail, business rather than clinical specialists. In addition, the physician-pharmacist interactions tend to be negative because pharmacists will usually only call physicians with bad news – that they made a mistake.

With 24 divisions, the Divisions of Family Practice model seems to be really taking off and advancing primary care. Their progressive and patient-centric approach is extremely important and they can be important allies in promoting health literacy and other key but often-neglected patient oriented interventions. However, is my colleague right – that they are failing to include pharmacists in their care teams? What are pharmacists doing to improve their interactions with and perceptions by physicians?

Last week, the BC government announced a $68.7-million Healthy Families BC strategy to “help families make healthy choices and introduce innovative approaches to challenges facing the health care system.”

The first program of this strategy is the $24-million Prescription for Health program intended to equip B.C. doctors with tools to assess and work with patients to develop a health promotion and illness prevention plan appropriate for them. The key elements of the program include the following:

• Prescription for Health is available to patients with at least one of these risk factors: smoking; unhealthy eating; physical inactivity and medical obesity.
• Patients can identify a lifestyle change goal, which will be documented by the physician on a Prescription for Health.
• The patient’s Prescription for Health may refer them to free-of-charge lifestyle programs to help patients achieve their individual lifestyle change goals. Examples of lifestyle support resources: the Physical Activity Line, Dietitian Services at HealthLink BC, QuitNow Services, a tobacco-cessation service and information resource, the Patient Voices Network peer coaching program.
• As an incentive, 50,000 participating patients can receive up to $50 toward programs that support their goals: gym membership, physical activity programs or nutritional programs.

For more information on Healthy Families BC or Prescription for Health, please visit www.healthyfamiliesbc.ca

I consider this a significant leap away the from the traditional focus on treatment to the more cost-effective prevention strategies – potentially avoiding up to $2 billion in yearly health-care costs. Obesity alone costs up to $830 million a year to the economy. What’s really fascinating is that patients get a financial incentive – it’s a really good idea to reward good behaviour. It will be interesting to see what the uptake of the program will be like, and what outcomes will result.

PVN provides impressive opportunities for consumer participation:

• An online community or virtual network of patients that register to provide input through response to surveys
• Activated network of trained patients who can be involved at three levels:
• Shaping the system: participating in focus groups, patient advisory committees and panel discussions; patient journey mapping
• Community Activation: working in patients’ local communities to improve primary health care
• Peer to Peer Coaching: supporting and motivating individuals to achieve healthy living goals.

One point that stood out for me was the positive approach that was emphasized by PVN. Patients’  may first be compelled to become activated members of PVN due to negative experiences with the healthcare system. While their frustration is understandable, it is important that theyare motivated by a desire to provide constructive feedback rather than hostile criticism.

Another highlight of the workshop was listening to Johanna Trimble speak about her involvement with PVN and what she has learned along the way. She had many positive experiences to relate but also cautioned participants to be balanced and acknowledge their limitations ie. not to volunteer for each and every opportunity.  Johanna, a steering committee member, has spoken at international conferences about her experience with the health care system and her presentation Is Your Mom on Drugs? – Find out what to do about it” is most compelling.

Our key messages include

• Why its good to ask questions about your medications: What medication am I  taking? Why am I taking this medication? How do I take this medication?
• Ways to ask questions to get the answers you need.

Our presentation to the Health Watch Program was very well received and we learned a great deal from the participants too.

• There were about 16 participants, many of whom listened while attending to important business such as taking weight and blood pressure readings and receiving massage sessions.

• They were an eager and engaged audience asking questions and making insightful comments through out the session. For example:
  • Do doctors keep as uptodate as pharmacists?
  • What does it mean to take medication with food? Does it have to be a full meal or can it be a snack such as a muffin?
  • Are vitamins better absorbed in powder rather than tablet form?

• We learned that the group actively supports members in taking charge of medication safety through:
• supply of medication booklets which members fill and carry
• keeping uptodate medication history records at the centre
• supply of vials used to store a dose of all of a patient’s drugs and corresponding list to be kept in the fridge. Emergency responders would be able to find this vial if the patient was unconscious.

Vials for storing medication accessible to emergency responders if patient is unconscious

• Despite being a group that interacts with pharmacists regularly, they picked valuable points. For example, they were not aware that all prescriptions dispensed in B.C. are tracked in the PharmaNet system and patients can walk into any pharmacy and the staff there will have access to their information.

• They recognized that
  • pharmacists are the most handy and accessible health care profession : “it is easier to talk to a pharmacist than a doctor”
  • pharmacists are a good source of information about the recommended daily requirements for vitamins and other supplements
  • 811 is the number to call for non emergency health information
  • the patient is the most important member of the healthcare team.

Seniors taking an active role in their health

Health Watch program in Burnaby, British Columbia struck me as a really unique program for promoting wellness among seniors. This calendar outlines some of their weekly activities.  Healthwatch along with three other programs  is part of the Burnaby Partners in Seniors Wellness. It is an excellent model of what can be done when seniors come together and are supported to take charge of their own health.

• The group is run by a volunteer board which plans and manages its activities. They request for funding from the Fraser Health Authority and have to report back on their activities.
• The funding is used to hire a coordinator who is shared by two programs.
• Retired health care workers have been recruited as volunteers to conduct screenings, monitor blood pressure and pulse etc.
• The group has secured permission to collect and maintain the health records of the participants. Volunteers fill out a medical card with vital information and give participants a wallet card. Weight and blood pressure are recorded each visit and an uptodate record of medications is maintained.
• Trained volunteers offer massage, conduct chair exercises
• Speakers are regularly invited to speak on various topics of interest to seniors such as our medication safety session.
• The seniors also enjoy socializing with their peers
• Partnering with local pharmacists t0 run a clinic  where seniors can bring in their drugs and have the pharmacist “critique” them. One of the seniors brought 21 different medications.
• Encourage their members to maintain an uptodate medication list.

Image credit: Used under creative common license Pocmont Resort and Conference Centre

Below are succinct snippets of mHealth wisdom not captured in the previous posts:

• lundelle RT @eedgerton mHealth can help throughout value chain: prevention/info; data collection; diagnosis; treatment/intervention; homecare. #mhs10 –
• RT @Hallicious: Right on: mHealth technology doesn’t have to be perfect. It just needs to be better than what exists today. – Dr Joseph Smith
• downeym Great point from audience member – don’t forget illiterate, tech-unsavvy users when making #mHealth solutions. Design well! #HCI #mHS10 –
• alshar Misalignment: Docs paid for procedures and hospitalization. Patients want avoid both. #mHS10 -
• stevemuse No real strategy in mHealth, gov, private sector doing innovative things, supply led direction, but what does society want #mhs10
• chloevdc audience member: ‘data is great for research and providers, interaction is needed for patients’ #mhs10
• chloevdc Rural telemedicine is happening in rural India already. Check out www.globalhealthpoints.com Big announcement tomorrow morning! #mhs10
• Mhealth is not  fad, delivers real outcomes – real value across chain; 30% of consumers willing to pay $2 on consultation Lisa D. Ellis, McKinsey & Company
• @billgates The major problems in a developing country are insolvable at a 3% per year population growth. #mhs10 (via @clickwisdom)
• mPuleio mHealth consideration: what is the key metric you are trying to improve?-Gates #mhs10

Through out the sessions, many speakers spoke about the potential of mHealth applications in western and global contexts. This post summarizes some of these.

Western projects

• Dr. Karen Clancy, AHRQ began by stating that 88% of MDs would like patients to monitor their health on their own – which makes it imperative to look into how mobile technology can support this. She then outlined some efforts to explore mobile enabled interventions:
  • Denver Health is testing the feasibility of using text messaging for care with elderly Hispanics with diabetes. Half of the patients have cell phones while the others had access via grandchildren. Doctors text patients asking for information about their blood sugar. This program has been well received – patients are enthusiastic and eager to participate.
  • Vanderbilt My Medihealth is a mobile personal health app to support homecare for kids with asthma. It entails a medication safety component. This application has the potential to address the enormous variation in rates of avoidable hospitalization in kids with asthma resulting in huge costs.
  • Salud mobile outreach program uses a mobile medical unit to reach Mexican migrants in rural areas. It follows patients where they are four nights a week. It has enormous appeal and is doing everything to provide patient centric care.

• RT @digiphile: Conditions like obesity, diabetes & smoking cessation are good candidates for #mhealth to address in rich countries, says @BillGates. #mhs10

Global projects

The summit shed light on the magnitude of global health challenges and why mobile health has such important potential particularly in maternal health.

• Babatunde Osotimehin, Ph.D., Professor of Medicine, University of Ibadan, Nigeria
  • Chilling statistic: since the beginning of the session, in Nigeria, 1000 women had  had died in child birth due to ignorance, poverty and lack of infrastructure
  • Wireless and cellphone communication is growing rapidly in Nigeria: In 1988, there were 0.4 M lines for 100 M people; today, GSM networks support 60 M cell phones for 150 M people.
  • Access to mobile technology is ubiquitous across economic strata – practically everyone has a cell phone. How can these technologies help address maternal mortality? Maternal mortality causes are complex but these technologies can provide information, educate and support the provision of services remotely.
  • Cell phone technology was successfully deployed to educate 200 000 women – advising them about their pregnancy, and very importantly, collecting valuable data about the births. As this technology is expanded, structures that generate real, quality data will help provide quality care over time.

• Christopher Tomlin Bailey, Coordinator, eHealth & Informatics, World Health Organization
  • Of note, the WHO Ehealth & Informatics group helps resource poor countries catalyze and adopt sustainable e-health solutions.
  • African countries often ask: What software is needed? More immediate questions: What’s your health system like, what do you want to accomplish and, what are your needs? Later, the issues of functionality and requirements need to be addressed before the software can be identified.
  • Is it feasible to replicate western systems? It’s good for them to learn from other models and what others have done but there are inevitable differences: For example,
    • in some parts of East Africa, standardized names are taboo – people use a diff name each time they access health services.  Aligning their EHR systems to international standards has to be done in a meaningful way.
    • Rwanda seeks a deidentified system to avoid a situation where the health system data can be used to identify and kill people – as tragically happened with the genocide.
  • A success story: in the Kenyan internally displaced camps,  mobile devices supported continuity of care for displaced patients who didn’t have identification. Rural clinics are benefiting from standardized EHR systems.

• Alex Ibasco Chief Innovation Officer – Strategic Business Development, Smart Communications
  • Average spend in the Phillipines is $4 for air time per month and 90% of people do not have smart phones
  • The Phillippines prone to Typhoons and tropical disease. Disaster aversion and management and disease control are priorities.
  • Mhealth involvement:
    • Enhancing communication with the next to the edge: to intermediaries [care givers] rather than the end users as mobile phone access is not yet universal
    • Data gathering for doctors [3 per hospital] – info about diabetic amputees for scheduling prosthesis
    • Echo system- connecting participants: bringing in the sources of funds, the payments – to ensure sustainable model

• Dr Julio Frenk, Harvard
  • The face of global health is changing – to realize full potential, institutions must innovate
  • Global health Context – health is a social objective, needs multi-sector engagement
  • Primary care is not primitive care – it is essential to transforming and extending healthcare reach
  • Connectivity key in quest for equity, continuity of care, access in remote care, timely responses

Global vs Western needs: Access vs Efficiency

• Thierry Zylberberg, Orange made the important distinction between the role of mhealth in developed and developing settings. To the Developed world: mhealth brings more efficiency, to the Developing world: access to health.
• It is essential to use the right application for the right environment. He gave examples of mhealth applications in different contexts such as
  • Europe: In Spain, people with diabetes and obesity can be remotely monitored.  The UK healthgateway program sends text reminders for appointments to improve efficiency. By 2011, mobile technology is to be used for the remote mgt of pacemakers and defibrillators.
  • Africa: In Cameroon, mobile technology is being used to send text messages for health education. In Egypt and Bostwana, teledermatology is supporting diagnostics from pictures, thus extending health services reach and access.

This post briefly outlines various themes that emerged.

• It’s not about technology – behaviour change is complex
  • RT @AudieAtienza:Vijay Vaitheeswaran “health depends on behavior & behavior is very difficult to change!” not about the technology… #mhs10
  • downeym “Bathroom scales have been around a long time, but we still have obesity.” –Vaitheeswaran at #mHS10
• Partnerships and collaboration are key
  • RT@mHealthAlliance Dr. Mwenesi, Tanzanian Health Ministry: Collaboration btwn public & private only way to move #mHealth forward #mHS10
  • Text4baby was repeatedly cited as an amazing success story of a private public partnership.
  • Partners should be drawn from relevant stakeholders in the eco system: Private [telecom industries], NGO; open source developers; public health system; community health workers
  • Ministries of Health must be involved– interventions need to be health demand driven not technology led. There is a risk of letting the technology experts lead the enterprise and yet they don’t realize the complexities of health systems.
  • South–to–south collaboration is essential as a sustainable approach which can promote equity.
  • Rockefeller didn’t want to replicate the same old silos – built mHealth alliance

• From pilots to full scale but where’s the funding?
  • The mobile technology landscape is characterized by many pilots with few scale-ups. Why? Lack of leadership and project management skills as well as sustainable funding models
  • The unrelenting criticism of pilotitis [ pilots that fail to scale into larger scope implementation]  was only matched by the scarcity of a clear strategy on a self sustaining business model that could evolve into a full scale, established service. The notable exception was text4baby which quickly became a nationwide project as a result of rare support from multiple partners and stakeholders including the White House. How easily can its success be replicated?

• Caution: user needs must come first

• • EndoGoddess David Gustafson says high volume Internet info/mobile health info can be conflicting/confusing to patient and may not result in improved health outcomes. #mhs10 –
  • kwalser We haven’t addressed what patients and families need [for #mHealth] to be truly helpful. – Dr. Gustafson #mHS10#ux#design#usability
  • It is important not to bombard the clinicians with too many alerts – some are about minor issues while others contradict one another
  • RT @haddadda: we should be designing mhealth applications with rather than for patients and health workers. #mhs10
  • For mHealth, it’s the responsibility of app developers to maximize ease for users, taking into account language & literacy #mHS10
  • We must address the issues of tinfrastructure. Automating poor paper records leads to equally poor EHRs, Louis I. HochHeiser, Humana, Inc. 
  • Just giving cell phones will not accomplish much: first understand the needs of the people/health care providers, perceptions, values, cultures – systems are not always transferable; use ethnography to characterize the needs of the people; involve end-users at the beginning of the project using participatory design Walter Curioso
  • Smart phones are the exclusive domain of the rich; realistic technology should focus on simpler phones
  • Simple health solutions –  reminders can be text messages but should be carefully designed; beyond the message, think about the right context. In Peru, people with HIV prefer the subtle coded message: it’s time for your…life in order to mitigate privacy, security and stigma issues

• mHealth helps collect data

• • mHealth outcomes can make an essential contribution to data collection which can support health system strengthening.
  • RT @mHealthAlliance: For CDC in Kenya, mobile data collection saves time and money. CDC now collects 20 times more health data than just a few years ago #mHS10
  • Michael S. Lauer cautioned that data collected naturalistically is not rigorous protocol – there will be missing information and it is hard to mine

• What mHealth is not [Lisa D. Ellis,  McKinsey & Company] 

• • a fad: it delivers real outcomes – real value across chain; 30% of consumers are willing to pay $2 on consultation
  • a technology game but change to business model and cultural behaviour worldwide – existing care regimens can be used
  • just about care delivery; can transform business model – for example how payors interact with patients submitting claims
  • a niche business: mobility is transforming many sectors around the world eg. in utilities, smart metering tech for consumption monitoring, retail and banking
  • a one solution fits all as models differ geographically
    • mature: delivery – where real savings are
    • emerging: reach – most rapid adoption of mobile health

• Healthcare systems and institutions must change to improve performance

• • Interventions cannot take place in a vacuum.: Leadership Institutions Systems Technologies (LIST required)
    • Leadership: strategy, vision, political skills and ethical perspectives
    • Institutions: development only  possible thru the vehicle of institutions that mobilize the pursuit of goals – hospitals…needs long term investments against political pressures
    • Tech: Knowhow to deliver appropriate interventions – biomedical as well ICTs to improve performance
    • Systems design – procurement, info, personnel so that requisite structures can mobilize the necessary resources

• Whether patients, providers, epidemiologists or policy makers…human oriented approaches are essential.

According to Wikipedia,

“mhealth (also written as m-health or mobile health) is a term used for the practice of medical and public health, supported by mobile devices… mHealth applications include the use of mobile devices in collecting community and clinical health data, delivery of healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vital signs, and direct provision of care (via mobile telemedicine).^“

I was able to follow some of the sessions via live webcast but mainly relied on the informative tweets of enthusiastic tweeple/tweeps (twitterers). In the next few posts, I will capture memorable tweets and my thoughts and reflections.

Pluses

• The conference was graced by such remarkable and influential thought leaders as Bill Gates and Ted Turner. It drew speakers from respected organizations like Rockefeller foundation – which lends important credibility and visibility to the growing mHealth field.
• The experts represented diverse areas: public and private; technology and health; rural and urban; policy makers, practitioners and academics. Such rich multisector dialogue with the resulting cross fertilization of ideas has promise of systemic impact.
• Despite its huge size, the summit provided an ideal forum for different players  to share ideas and lessons learned. The global health arena is highly prone to fragmented and uncoordinated interventions fraught with wasteful duplication rather than productive collaboration. mHealth Alliance’s Health Unbound was promoted  as precisely the forum to promote knowledge sharing and collaboration in the mHealth community.
• The conference afforded the rare opportunity to address the potential of mHealth in both western and global contexts:
  • @downeym New #mHealth trend in the developing world – extending clinic into remote villages via mobile tools & health workers. – @pbiondich #mHS10
  • RT @AIDSgov: At #mHS10, we’re exploring how mobile technology can improve domestic HIV programs. Read our #mHealth blog post: http://go.usa.gov/C8Z

It was particularly heartening to note the recognition that developing countries are further along in these technologies as they a) have had to be more innovative and b) have not been hindered by legacy systems which tend to interfere with the adoption of new technologies. It is a refreshing shift when the north finds positive lessons to learn from the south.

• MSHHealthImpact #Gates: richest countries much less innovative health-wise than middle-income countries and least developed countries. #mhs10 #globalhealth

Minuses

• Some seasoned tweeps, notably @downeym who attended mHealth 2009 summit reported a déjà vu feeling as the same issues came up. According to @downeym, the previous summit mainly featured “doers” while the 2010 summit was dominated by “talkers”.
• Awareness is a good thing but there was valid concern that the summit overhyped mobile phones as the antidote to all global health problems, creating unrealistic expectations. Is mHealth  yet another bandwagon that will, predictably, underdeliver?
• It is challenging to meaningfully address both the global health challenges and western perspectives in the same forum because the contexts differ significantly. There may be transferable experience but the different regions have unique challenges and needs.
  • Thierry Zylberberg, Orange aptly highlighted this when making the distinction between the role of mhealth in developed and developing contexts: To the Developed world: mhealth brings more efficiency, to the Developing world: access to health. Needless to say, it is essential that the application is appropriate for the environment.
  • RT @clarkritchie: In the US, mobiles are personal devices, but in many other cultures they are shared or communal #mhs10