Objectives Identify the increasing applications of mobile - PDF document

4/23/2019 Use of Mobile Health Technology for Medication Adherence Chris Blosser May 4, 2019 Objectives • Identify the increasing applications of mobile technology in healthcare • Explain the concept of Patient-Centered Healthcare • Assess the impact of medication nonadherence on healthcare • Review a pilot study of mobile healthcare application in kidney transplant recipients Conflict of Interests • Funding commitment for Pilot Study – TapCloud, LLC 1

4/23/2019 Forbes.com; The International Telecommunication Union 2

4/23/2019 Patient Role in Healthcare Institute of Medicine report, Crossing the Quality Chasm Patient-centered care should be "respectful of and responsive to individual patient preferences, needs, and values and ensure that patient values guide all clinical decisions.” (2001) Patients are encouraged to take an active role in their own healthcare safety. Patient Communication On Mar 30, 2016, at 11:35 AM, • EMR-based Patient • Dear Dr. Blosser, Email • As you probably know my wife, _______. was hospitalized on the last Sunday and the • UW Email kidney was transplanted on Monday, March 28th. • Office phone calls • This is very exciting news for our family after 6 years of not stop dialysis 3 times per week. • Text messages _____ is recovering and they say everything • • Cell phone calls is going well and she may be discharged on the end of this week, possibly Friday. • We would like to ask you ******. Please let us know, [if] it is possible. • Many thanks ****. • Sincerely, _______________________ Do Patients & Providers See Medical Technology the Same? • 2508/21812 Medscape healthcare professional members completed emailed 15 item survey • 1102/456,243 consumers completed same survey • Topics: o New Medical Technology for self-diagnosis of non-life threatening condition o Privacy o Medical Health Records o Cost & Transparency o Physical Exams & Imaging Boeldt DL, et al. J Med Internet Res. 2015 Sep 14;17(9):e215. 3

4/23/2019 Who owns medical record & does patient access alter outcomes? Boeldt DL, et al. J Med Internet Res. 2015 Sep 14;17(9):e215. • Medicine is at it’s “Gutenberg moment” • Mobile internet -> Digitized and Democratized healthcare. • Shifting to patient- directed data- gathering, analysis and intervention model, that may be cheaper. 4

4/23/2019 mHealth 24% Research.technologyadvice.com Eric Topol, The Creative Destruction of Medicine Future Healthcare Patient-Centered and Reported Care Healthcare System • (image of fraying end of rope) Mobile Technology 5

4/23/2019 Real World Usage of mHealth Monitoring Device • 3872/4525 completed the crowdsourced email inviting participation in use of multi-parameter vital sign monitor. • Aim: Identify factors associated with consistent long-term use of the monitor. Waalen J, et al. (2019) PLOS ONE 14(4): e0215468. Amount of device usage by total time in study. Consistent Long-Term Use [>26 wks, 3x/wk, >80% wks] • Older adults • No children at home • Use other medical devices Waalen J, et al. (2019) PLOS ONE 14(4): e0215468. Risks with Revolution • Privacy risks – 43% of identity theft via healthcare records in 2013 • All digitized equipment is at risk of data theft or cyber attack, including pacemakers and dialysis machines • With autonomy comes personal responsibility 6

4/23/2019 Reasons for Nonadherence “Drugs don’t work in patients who don’t take them.” C. Everett Koop - Active Nonadherence - Passive Nonadherence Walgreen Co, 2014; https://www.hlc.org/wp-content/uploads/2014/05/Walgreens-Slides.pdf Osterberg L, Blaschke T. NEJM 2005 Impact of Nonadherence https://www.hlc.org/wp-content/uploads/2014/05/Walgreens-Slides.pdf 7

4/23/2019 Osterberg L, Blaschke T. NEJM 2005 Patient vs Medical- Centered Outcomes • Solid organ transplantation has improved recipients’ survival quality of life (QoL) dramatically. • Yet, kidney transplant recipients have lower QoL scores compared with their healthy peers. • Providers measure transplant outcomes with quantitative measures • Organ recipients commonly measure transplant outcomes in qualitative measures, i.e. how they feel, incl. how medication regimen affects day- to-day function. Young Adult KTRs at Risk • 22yo male, ESRD of unknown etiology s/p DDRT 2007 • Baseline Scr 1.4 • Presented 3/2015 with Scr 2.1 • Admitted not taking meds consistently • Started drinking Etoh regularly • Why? 8

4/23/2019 Young Adulthood • Physical, cognitive, social & psychological development • Preoccupation with body image • Identity search • Questioning authority • Risk Taking • Substance abuse • Suicide Chronic Illness & Youth • Don’t fit into common paradigm of transplant care • Compete with ever-aging population • Isolated from peers, both healthy & those with same medical conditions Perry EE. Renal Fail 2011 Young Adult Graft Survival • Over 90% of18-34yr old 5-year Graft Survival Among Living Donor Adult Kidney Transplant KTRs are alive at 5 years Recipients, 2009 but the 10-year survival is much less favorable. • Adjusted 5-year graft survival for this age group is lower than older cohorts. Figure KI 5.4. 2014 OPTN/SRTR Annual Report 9

4/23/2019 Intrapatient Variability • Within-Patient CV < 30% Variability in Tacrolimus Blood Levels Predicts CV > 30% de novo DSA, antibody-mediated rejection and kidney graft Loss. Rodrigo E, et al. Transplantation 2015 Allograft Survival: Late acute rejection free time Vlaminck, H., et al., American journal of transplantation, 2004. 4 (9): p. 1509-13. Adherence Interventions • Standard of care for Kidney Transplant Recipients includes regular clinic visits and adherence education, yet there is much room for improvement. • Many age-specific interventional tools are available for improving adherence in the kidney transplant population. 10

4/23/2019 Adherence Interventions • Large majority (85%) of young adults in U.S. are smartphone owners • ~75% of 18-29yr olds used their phone in the last year to access health information • Potential for healthcare applications and mHealth is intuitive. Pew Research Center, http://www.pewinternet.org/2015/04/01/us-smartphone-use-in-2015/ TapCloud Application • Patient-oriented application that o Integrates patient-reported information, o Medication reminder system o Patient-provider communication link. • Functions allow patients and their care teams to plan, track, alert, and communicate in real time. 11

4/23/2019 TapCloud Application Two sides to TapCloud: • Patient-facing app works on any smartphone or tablet  Patient-reported Information  Medication and Appt Reminders  Data tracker Private, secure communication link  • Provider dashboard for patient monitoring and alert system Patient Platform Provider Dashboard 12

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4/23/2019 SMART Pilot Study Smart Phone Application to Improve Renal Transplants • Investigator-initiated prospective pilot clinical trial of prevalent 18-34 year-old kidney transplant recipients in the UW Transplant Program • Goals: Assess the feasibility and efficacy of the TapCloud application over 3 months, compared with standard of care, at improving Quality of Life SMART Pilot Study Smart Phone Application to Improve Renal Transplants SPECIFIC AIM 1: • To examine the feasibility of a mobile interactive health care platform, TapCloud, measured by participant enrollment and usage frequency by young adult kidney transplant recipients over 3 month follow-up. SMART Pilot Study Smart Phone Application to Improve Renal Transplants • SPECIFIC AIM 2: To assess patient and provider experience with TapCloud platform measured by clinically-relevant outcomes and qualitative surveys in young adult KTRs and their transplant providers over 3 month follow-up. 14

4/23/2019 SMART Pilot Study Smart Phone Application to Improve Renal Transplants • SPECIFIC AIM 3: To characterize the impact of a mobile interactive health care platform, TapCloud, on Quality of Life (QoL) and self-efficacy in young adult kidney transplant recipients (KTRs). Kidney Transplant Questionnaire-25 • KTQ-25 developed by kidney transplant recipients and clinical experts. • 25 items - classified in 5 domains: o Physical symptoms o Fatigue o Uncertainty/fear o Appearance o Emotions • Responses on a 7-point Likert scale. • Lowest score represents the lowest quality of life. • For the analysis, all scores in each domain are added and divided by number of items in that dimension. Laupacis et al., Nephron 1993 Inclusion and Exclusion Criteria Inclusion Criteria Age 18 – 34 years Kidney Transplant Recipient eGFR >20ml/min/1.73m2 Exclusion Criteria Lack of continuous access and ability to use a smart phone Lack of continuous access to ability to use internet Not taking calcineurin inhibitor (e.g. tacrolimus, cyclosporine) Currently on acute or chronic dialysis 15