Innovative methods to educate patients and providers, promote adherence, and enhance communication both between patients and providers and among providers across different settings have become available through the growth of computer-based technologies. Interactive web- or mobile phone-based programs are often broadly referred to as mobile health or “mHealth,” a term that we will use here to encompass any patient-facing computerized health technology. Examples of mHealth include systems that monitor patients’ progress toward physical activity goals, assess risk of disease, remind patients to take medications, or provide the information patients need for more informed decision making. While most patients with chronic diseases struggle with self-care, innovations such as these may have the greatest impact on improving the care of vulnerable patients, who often face barriers to accessing health information and support via face-to-face encounters with clinicians and other helpful social network members.

Access to the Internet is becoming commonplace. Recent surveys by the Pew Research Center report that 85% of Americans use the Internet and 91% have mobile phones (including 56% who have smartphones with Internet access).¹ Most importantly, the differences in Internet and mobile phone use by race/ethnicity and socioeconomic status have been shrinking rapidly. Similarly, there has been an explosion in the use of mHealth technology in health-care settings, such as the introduction of personal electronic health records for patients and the availability of thousands of mobile phone applications for managing a wide range of health and health-care topics. Even when examining the uptake of technology internationally, it is clear that the digital divide is shrinking between low- and high-income countries as well, with mobile phone coverage and use growing quickly worldwide. In fact, many of the lessons learned from implementing technology interventions in low- and middle-income countries are particularly informative for improving the health and health care of vulnerable patients in the United States.^2,3

While the use of the Internet and mobile phones continues to climb, the frequency and type of technology access can differ among low-income patients, especially when considering Smartphone ownership and broadband Internet access. Unless these gaps in technology access are addressed, information tools that require personal computer or Smartphone use will continue to present challenges for socioeconomically vulnerable communities.

In addition, socioeconomically vulnerable patients often have limited health literacy,⁴ limited English proficiency, or other communication challenges that serve as formidable barriers to the use of most standard mHealth services. Consequently, these patients may have difficulty accessing “off-the-shelf” mHealth solutions, even when those technologies have proved beneficial for other patient groups. A recent review of the evidence found that studies reporting on the usability of diabetes Internet and mobile phone applications rarely addressed issues of accessibility for diverse or vulnerable patients.⁵ Despite these potential barriers, safety-net health systems striving to improve treatment access and quality can use mHealth successfully if careful attention is given to how those services are designed.⁶

This chapter discusses the principles that should drive the design and development of mHealth services so that they are accessible and effective in diverse populations of patients. The focus is primarily on the use of mHealth to promote more effective communication and disease management among patients with chronic health problems, such as diabetes, heart failure, or depression. These patients represent the majority of visits and uncompensated health-care costs within safety-net heath systems. Such patients often lack the resources required to manage their condition successfully, and access barriers significantly add to the difficulty of meeting the demands of their illness. Rather than focus on specific types of mHealth technology (such as web-based applications or interactive voice response systems), the chapter focuses on concepts that are relevant for most currently available technologic platforms. Each health-care system must choose the appropriate platform for delivering the health technology programs outlined below—whether it be texting, automated telephone calls, clinic-based multimedia supports, or other web-based programs. Matching existing technologies to the skills and capacity of both the patient population and current care processes within the health-care setting will best utilize mHealth solutions to address gaps in care.

When implemented effectively, mHealth can be helpful in redressing the difficulties faced by safety-net health-care systems and the patients they serve. Financial access barriers, geographic distance, language barriers, long waiting times, and restrictive work schedules all conspire to make typical face-to-face communication within outpatient settings especially difficult for socioeconomically vulnerable patients.⁷ In general, mHealth technologies can assist patients to get support managing their chronic conditions either through direct communication with providers or access to relevant health and self-management information. Many chronically ill patients may need weekly or even daily support for their self-care; however, such demands strain even the most effective care management systems and are impossible to meet by most safety-net providers. Many patients within safety-net health-care systems are complex and often have ­multiple chronic comorbidities which make the prioritization of discussion topics with their provider even more challenging.^8,9 Despite the obvious importance of ­clinician–patient communication, health-care providers often are unaware of patients’ self-management goals¹⁰ or the financial ­pressures that patients struggle with because of their treatment,^11,12 issues that may be clarified and communicated to the provider through mHealth programs.

Many mHealth-based disease management interventions (particularly those developed in the early 1990s) attempted to address multiple self-management problems simultaneously. Earlier enthusiasts of these new technologies seemed to operate based on the expectation that (because they were so novel and exciting) technology-based interventions per se would have a therapeutic benefit, and therefore careful consideration of intervention goals was less important. However, like all clinical services, mHealth-based services are most effective when they are designed with specific, targeted goals in mind (Box 17-1).

USING MHEALTH TECHNOLOGIES TO SUPPORT ADMINISTRATIVE PROCESSES OF CARE

Chronically ill patients face a daunting task when managing their health problems: handling numerous medications, coordinating repeated visits to different clinicians, and navigating the continually changing requirements for insurance or benefits. Even those with insurance can be financially strained by the costs of treatments and medications. Studies indicate that chronically ill patients have difficulty meeting these administrative challenges, particularly if they have little education or limited English proficiency. Patients often miss scheduled appointments, and no-show rates are often highest among individuals with the greatest need for clinical care.¹³ More than one-third of diabetes patients with either no health insurance or Medicaid coverage reported forgoing prescription drug use in the prior year because of cost concerns, despite the fact that those patients were almost universally eligible for first-dollar medication coverage through state and regional financial assistance programs.¹²

mHealth programs can assist patients managing the complexity of their health service use as well as their self-care. Automated reminder calls delivered via a computerized “interactive voice response” (IVR) telephone system to patients undergoing medication treatment for tuberculosis increased visit attendance rates relative to controls.¹⁴ Even though patients were not aware that IVR reminders would be coming to their homes, the calls were effective for patients with a variety of primary languages, including Mandarin, Vietnamese, Tagalog, and Spanish. Other studies have found that automated reminders can increase attendance rates for routine vaccinations¹⁵ and can assist patients in taking their medications as prescribed.¹⁶ Importantly, “low-tech” alternatives to automated telephone calls (such as reminder letters) also improve attendance rates,¹⁷ but IVR reminders are cost-effective when compared with these more labor-­intensive alternatives. High patient engagement with IVR technologies has also been documented in low- and ­middle-income countries, suggesting that this approach for chronic disease self-management support is adaptable for diverse patient populations.^2,3,18 The technology used to deliver IVR reminders is relatively simple and inexpensive (especially with the increased ability to employ very low-cost voice over IP (VoIP) technology to deliver the calls),¹⁹ and the research in this area is sufficiently definitive that safety-net providers should consider incorporating such reminders into usual outpatient care.

Other forms of mHealth, such as text messaging to cell phones, may be effective in assisting vulnerable patients with the administrative functions of their disease management. Recent systematic reviews have found that texting can significantly improve appointment adherence and self-efficacy for chronic disease self-management, but there is far less evidence that such interventions can improve clinical outcomes such as glycemic or blood pressure control or weight loss.^20,21 In addition, texting programs have been shown to improve smoking cessation rates.²² However, there have been fewer studies of texting conducted in socioeconomically vulnerable patient populations. Among patients in one safety-net system in Chicago, patients reported high satisfaction rates with texting programs for medication reminders, as well as self-reported improvements in medication adherence and overall confidence in diabetes self-management.²³

Finally, the introduction of personal electronic health records, or patient portals, may assist patients in managing the administrative tasks associated with their chronic illness care.²⁴ These systems can provide patients with access to a variety of functions associated with their care: from secure email with providers and staff; viewing visit summaries, lab results, and medical histories; and online appointment scheduling and refill requests. Studies in large delivery systems such as Kaiser, Group Health, and Cleveland Clinic have reported that patients with access to portals are more likely to have improved diabetes control,^25,26,27 suggesting that the convenience of completing several administrative tasks may be linked to better outcomes. Patient access portals or secure emailing with providers has been more limited in safety-net systems, but there is high interest in electronic communication with health-care providers among this patient population.^28,29 The introduction of portals into safety-net settings in the next few years with US health reform will provide a wealth of opportunities for evaluating their potential.^30,31,32

USING MHEALTH TECHNOLOGIES FOR ONGOING PATIENT MONITORING

Most patient monitoring occurs as reactive care during relatively infrequent face-to-face outpatient visits. Few health systems have the information systems needed to trigger a proactive and comprehensive assessment when patients seek care through different entry points (e.g., an emergency department), and many patients have difficulty keeping scheduled office visits.³³ Consequently, chronic disease treatment plans often reflect patients’ historical problems more than their current needs, opportunities to prevent health crises are missed, and educational efforts lack the timeliness needed to be effective.

mHealth can assist clinicians in gathering up-to-date information about patients’ health status and behavioral needs. For example, low-income patients with diabetes in the United States and abroad can and will complete brief IVR assessments of their glucose self-monitoring values and self-management behaviors.^34,35 Engagement is also high across a variety of health-care conditions, such as programs for heart failure, cancer, diabetes, and depression. These applications appear to be especially useful for patients with limited English proficiency.^36,37 IVR data are often reliable even when reported by individuals with psychiatric disorders.³⁸ Such assessments can accurately triage patients into groups with high-, medium-, and low-risk for adverse outcomes.

A rapidly growing area of technology development has been the design and testing of remote monitoring applications that can track patients’ clinical data without relying on patients’ self-reports. A recent randomized trial of veterans with back pain found that pedometers that uploaded physical activity to a website with personalized walking goals, feedback, motivational support, and social support resulted in greater decreases in pain-related disability.³⁹ Incorporating external device information from glucometers and blood pressure cuffs uploaded into mobile phone applications or websites can be particularly appealing if passive data capture provides both more accurate and larger amounts of data to understand a more complete picture of self-management. A randomized controlled trial of telemedicine with remote monitoring of blood pressure and blood glucose among low-income Medicare patients in New York found significant improvements in A_1c, blood pressure, and low-density lipoprotein control.⁴⁰ Similarly, patients with hypertension receiving IVR automated telephone self-management support with home blood pressure monitoring in Honduras and Mexico also showed improved blood pressure control, reduced medication nonadherence, better overall health status, and higher satisfaction with care.⁴¹

Careful consideration must be given to the ways in which health systems respond to mHealth-reported information. While the effectiveness of such systems has been documented, there are a range of issues related to implementation into an existing clinical setting, such as willingness of staff and providers to use the technology and new data sources.⁴² Clinic-based “case finding” or screening with feedback to providers can have little impact on patient outcomes,^43,44 often because providers have limited ability to change practice patterns or because treatment changes are not tightly linked with health outcomes. Providers who are pressed for time or treat patients with multiple urgent complaints often lack the resources required to follow up effectively on serious, but chronic patient needs (e.g., dysthymia, functional limitations, or self-management problems). mHealth-based patient monitoring with limited clinical ­specificity may generate unnecessary outpatient visits, straining scarce resources in public clinics, and indirectly denying access to other patients with acute health concerns. Given the state of the science in mHealth patient monitoring, ­safety-net ­providers should carefully consider the frequency and content of mHealth assessments, and the implications of both erroneously identifying patients as having ­serious health problems versus missing problems because of “false-negative” reports.

USING MHEALTH TECHNOLOGIES FOR PATIENT EDUCATION AND SELF-MANAGEMENT SUPPORT

Patients with chronic illnesses require enormous amounts of health information that change with the disease course. Unfortunately, providers infrequently engage in the types of communication behaviors that are associated with greater patient retention and understanding,⁴⁵ and many are unaware of their patients’ self-management goals.¹⁰ When patients face language barriers or health literacy deficits, many lack even rudimentary information about their disease or its self-care.⁴⁶

mHealth can provide patients with the information they need at a time when they are best able to assimilate it. Unlike written patient education material, mHealth resources such as those provided via the web can be multimodal (i.e., including graphics, video, and audio) and provide information at a pace that is comfortable for users.⁴⁷ Importantly, the information provided by mHealth can be tailored to patients’ unique socio­demographic, clinical, and psychological characteristics; and studies show that such tailoring can be important in prompting behavior changes.⁴⁸ For example, patients with diabetes are interested in receiving health education via mHealth,⁴⁹ and non-English speakers treated in public clinics may be especially interested in accessing IVR health education with practical information or inspiring messages about self-management, such as how to cope with medication side-effects and how to cook healthy meals.⁵⁰ Patients with diabetes from a safety-net clinic who received weekly IVR messages over a 9-month period also reported significant improvement in their self-management behaviors and functional status, as well as greater improvements in these outcomes when compared with patients who attended monthly group medical visits and usual care.⁵¹

Most patients remember only a small proportion of the educational messages provided during typical outpatient encounters.⁵² Given that many patients spend a significant amount of time waiting to be seen by clinicians, safety-net health systems should consider making interactive kiosks available within outpatient settings,⁵³ which can provide self-guided educational content about a wide variety of health topics through a standalone computer. Recent research has demonstrated that kiosks can be a viable education tool in safety-net clinics, pharmacies, and community centers. One study reported as many as 600 uses per month, with the most viewed modules for recipes and meal planning.⁵⁴ Another similar study found that kiosks in community settings with personalized information about self-care management could improve self-reported diet and physical activity among Latino patients.⁵⁵

Additional research has explored the use of embodied conversational agents or avatars to deliver health education and promotion content, delivered either through clinic kiosks or on tablets that can also be accessed at home. This conversational agent technology may better capture aspects of in-person communication by using dynamic verbal and nonverbal conversational behaviors, and it has been shown to be an effective way to communicate with patients with limited health literacy.⁵⁶ It has been shown that this approach could also increase physical activity among older adults in the short term.⁵⁷

Models for computer-assisted self-management education are available,⁵⁸ and research shows that they can assist patients in identifying self-management goals and barriers, and ultimately improving their self-care. In the context of busy primary care practices,⁵⁹ such services can address patients’ need for self-management education without adding tasks to the schedules of primary care providers.

USING MHEALTH TECHNOLOGIES TO FACILITATE INFORMAL PEER SUPPORT

Safety-net health systems are often poorly positioned to address patients’ need for assistance in coping emotionally with their illness, and mental health insurance benefits are typically inadequate to meet patients’ need for counseling. Chronic illness can present an enormous emotional drain on patients. Depression is common among patients with diseases such as diabetes and heart failure,^60,61 and patients with comorbid psychiatric problems often have worse outcomes^62,63

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