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CHRONIC CARE IN THE TIME OF TECHNOLOGY
Take Two Tablets and an App for that.......
Dr. Mait O FaolainMB BCh BAO MRCPI MICGP DRCOG Masters in Business Management
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The Times They Are A-Changin
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The Times They Are A-Changin
Come gather ‘round peopleWherever you roamAnd admit that the watersAround you have grown......
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The Times They Are A-Changin
Come gather ‘round peopleWherever you roamAnd admit that the watersAround you have grown......
......If your time to youIs worth savin’Then you better start swimmin’Or you’ll sink like a stone
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General Practice: What we do Best
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General Practice: What we do Best
General Practice = Communication Specialty
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General Practice: What we do Best
General Practice = Communication Specialty
Patient Satisfaction Literature for 1° Care
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General Practice: What we do Best
General Practice = Communication Specialty
Patient Satisfaction Literature for 1° Care Communication
Smith, C.H., Armstrong, D. (1989) „Comparison of criteria derived by government and patients for evaluating general practitioner services‟. British Medical Journal, Vol. 299 pp. 494-496
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General Practice: What we do Best
General Practice = Communication Specialty
Patient Satisfaction Literature for 1° Care Communication Consistency of Doctor
Smith, C.H., Armstrong, D. (1989) „Comparison of criteria derived by government and patients for evaluating general practitioner services‟. British Medical Journal, Vol. 299 pp. 494-496
Hall, J.A., Dornan, M.C., (1990) „Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Social Science and Medicine Vol. 30, pp. 811-818
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General Practice: What we do Best
General Practice = Communication Specialty
Patient Satisfaction Literature for 1° Care Communication Consistency of Doctor
Patient involvement in decision making
Smith, C.H., Armstrong, D. (1989) „Comparison of criteria derived by government and patients for evaluating general practitioner services‟. British Medical Journal, Vol. 299 pp. 494-496
Hall, J.A., Dornan, M.C., (1990) „Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Social Science and Medicine Vol. 30, pp. 811-818
Sixma, H.J., Kerssens, J.J., (1998) „Quality of care from the patients‟ perspective: from theoretical concept to a new measuring instrument‟. Health Expectations Vol. 1 pp. 82 -95
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General Practice: What we do Best
Patient Satisfaction Literature for 1° Care Communication Consistency of Doctor Patient involvement in decision making Accuracy + Accessibility
Smith, C.H., Armstrong, D. (1989) „Comparison of criteria derived by government and patients for evaluating general practitioner services‟. British Medical Journal, Vol. 299 pp. 494-496
Hall, J.A., Dornan, M.C., (1990) „Patient sociodemographic characteristics as predictors of satisfaction with medical care: a meta-analysis. Social Science and Medicine Vol. 30, pp. 811-818
Sixma, H.J., Kerssens, J.J., (1998) „Quality of care from the patients‟ perspective: from theoretical concept to a new measuring instrument‟. Health Expectations Vol. 1 pp. 82 -95
Wensing, M., Jung, H.P., Mainz, J., and Grol, R., (1998) „A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain‟. Soc. Sci. Med. Vol. 47. No. 10, pp.1573-1588
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Fundamental Question
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Fundamental Question
As Patients are happy with what we do why do we need to change?
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Fundamental Answer
As Patients are happy with what we do why do we need to change?
Our Patients are changing.....
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Fundamental Answer
As Patients are happy with what we do why do we need to change?
Our Patients are changing.....
.......Our Days are getting Busier.
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Plus ça change...
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Plus ça change...
ESRI predicts a rise in GP consultations of 33%
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Plus ça change...
ESRI predicts a rise in GP consultations of 33%
2005: 11.1m
2021: 14.8m
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Plus ça change...
ESRI predicts a rise in GP consultations of 33% 2005: 11.1m 2021: 14.8m
Doesn’t account for Chronic Disease Programme!
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Plus ça change... Busier Days
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Plus ça change... Busier Days
Growing Population
11% increase by 2021
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Plus ça change... Busier Days
Growing Population
Aging Population
Average number of visit increase with age
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Plus ça change... Busier Days
Growing Population Aging Population
Changing Health Care System
Chronic Disease Programme
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Plus ça change...
.
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Plus ça change...
...Plus les choses ne peuvent rester les
mêmes.
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Plus les choses ne peuvent rester les memes
Pour Quoi?
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...n’est pas rester la meme...
Our Patients are changing.....
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Ce n’est pas la même chose
Growing Population
Birth = Young people not Old People
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Ce n’est pas la même chose
Growing Population Birth = Young people not Old People
Ageing Population
Next decades Pensioners are Last Decades 45 y.o
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Ce n’est pas la même chose
Growing Population Ageing Population
Next decades Pensioners are Last Decades 45 y.o
Chronic Disease Programme
Diseases that benefit from Early Stage Intervention
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Ce n’est pas la même chose
We must do more with less – James Reilly
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Ce n’est pas la même chose
We must do more with less – James Reilly
We must do more DIFFERENTLY with less
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The Answer
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The Answer
Technology
iPhones and iPads
Apps
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Why Technology
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Ireland is Wedded to Technology
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Technology Usage Ireland
5.4 Million Mobile Phones 119% Population penetration
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Technology Usage Ireland
5.4 Million Mobile Phones 119% Population penetration
3.2 Billion SMS (Text Messages)
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Mobile Phones by Age
100
99
9996
95
90
% Mobile Phone
16-1718-2425-3435-4950-6465-74
Q4 2011 Com-Reg
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Internet Usage 2000-10
YEAR Users Population % Pop. Usage Source
2000 784,000 3,755,300 20.9 % ITU
2002 1,319,608 3,780,600 34.9 % Nielsen NR
2008 2,060,000 4,156,119 49.6 % C.I. Almanac
2010 3,042,600 4,622,917 65.8 % ITU
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Laptop by Age
82
91
86
82
70
55
% Laptop
16-1718-2425-3435-4950-6465-74
Q4 2011 ComReg
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Technology Usage Ireland
4.2 million 3G Sim Cards (80% Phones)
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Technology Usage Ireland
4.2 million 3G Sim Cards (80% Phones)
1.65m Broadband Subscriptions
55% of Household Penetration
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Why Tablets and iPhones
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Tablets by Age
12
10
13
10
11
5
% Pop iPad or Tablet
16-1718-2425-3435-4950-6465-74
Q4 2011 Com-Reg
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SmartPhones
49% population 2011
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SmartPhones
49% population 2011
Estimated 71% population 2012 (Red C)
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SmartPhones
49% population 2011 Estimated 71% population 2012 (Red C)
80% Smartphone users research purchase decisions (Google)*
*Our Mobile Planet; Ireland, understanding the mobile consumer, May 2012, Google
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Why Chronic Care
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Why Chronic Care
5,000 Hours Concept
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Why Chronic Care
5,000 Hours Concept
Average person = 5,000 hours Awake every year
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Why Chronic Care
5,000 Hours Concept Average person = 5,000 hours Awake every
year
Chronic Disease Pt spends ~10 hr/yr with HCW
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Why Chronic Care
5,000 Hours Concept Average person = 5,000 hours Awake every
year Chronic Disease Pt spends ~10 hr/yr with
HCW
99.98% of waking hours spent self-caring.
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Why Chronic Care
5,000 Hours Concept
Economics
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Why Chronic Care
5,000 Hours Concept
Behavioural Economics
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Why Chronic Care
5,000 Hours Concept
Behavioural Economics
People are rational self-interested actors who DON’T always do what is in their own self-interest
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Why Chronic Care
5,000 Hours Concept Behavioural Economics
People are rational self-interested actors who don’t always do what is in their own self-interest
Life gets in the way.
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Why Chronic Care
5,000 Hours Concept Behavioural Economics
Nudges can get life back out of the way
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Why Chronic Care
5,000 Hours Concept Behavioural Economics
Nudges- Small non-intrusive actions/reminders that
prompt people to do what is in their own interest.
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Is Smartphone Technology the Answer?
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Smartphone Technology
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Smartphone Technology
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Smartphone Technology
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Smartphone Technology
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Smartphone Technology
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Smartphone Technology
Smartphone Peripherals Fun but a little Frivolous
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Smartphone Technology
Smartphone Peripherals = Frivolous
The true strength of iPhone technology lies elsewhere
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Apps
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Apps
App = Application (Computer Programme)
Written for Mobile Technology platform iPhones, iPads, Android Smartphones/Tablets
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Apps
App = Application (Computer Programme)
Written for Mobile Technology platform
Simple to write
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Apps
App = Application (Computer Programme)
Written for Mobile Technology platform Simple to write
Do Simple Things
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Smartphone Apps
Do simple things very well
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Smartphone Apps
Apps do simple things very well
Educate
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Smartphone Apps
Apps do simple things very well Educate
Record Metrics
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Smartphone Apps
Apps do simple things very well Educate Record
Automate Algorithms
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Smartphone Apps
Apps do simple things very well
Smartphones always in our pockets
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Smartphone Apps
Apps do simple things very well Smartphones always in our pockets
Ideal Tool for Chronic Disease Nudges
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Apps in Chronic Disease Delivery
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Apps in Chronic Disease Delivery
CHRONIC DISEASE PROGRAM
Asthma COPD
Stroke A.C.S
Heart Failure Diabetes Mellitus
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Apps in Chronic Disease Delivery
CHRONIC DISEASE PROGRAM
Shared Features of Disease Programmes
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Apps in Chronic Disease Delivery
CHRONIC DISEASE PROGRAM
Shared Features of Disease Programmes Education Important
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Apps in Chronic Disease Delivery
CHRONIC DISEASE PROGRAM Shared Features of Disease Programmes
Education Important
Simple Metrics signal deterioration
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Apps in Chronic Disease Delivery
CHRONIC DISEASE PROGRAM Shared Features of Disease Programmes
Education Important Simple Metrics signal deterioration
Well Defined Management Algorithms
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Apps in Chronic Disease Delivery
Shared Features of Disease Programmes Education Important Simple Metrics signal deterioration Well Defined Management Algorithms
Early Intervention prevents Complications and Hospitalisations
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Case Study Example:
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Case Study Example:
Asthma Program
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Asthma Program
No firm details yet
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Asthma Program
No firm details yet
Will be based on GINA / ICGP Guidelines
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Asthma Program
No firm details yet Will be based on GINA / ICGP Guidelines
? Payment based on achieving the 4 Steps
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GINA / ICGP Guidelines
Part 1: Risk Factor Reduction
Part 2: Guided Self Management
Part 3: Assess – Treat- Monitor
Part 4: Manage Exacerbations
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1: Risk Factor Reduction
Trigger avoidance
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Trigger Avoidance
Pollen Count App linked to Met Eireann forecasts
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1: Risk Factor Reduction
Trigger avoidance Pollen Count function in an APP
Good Medical Control
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Good Control
Record of Peak Flows App based regular recording of same
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Good Control
Record of Peak Flows App based regular recording of same
Automatic alert when period of no in-put
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Good Control
Record of Peak Flows App based regular recording of same Automatic alert when period of no in-put
Warning Alert + Advice if Peak Flow < Predicted/ Best
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Good Control
Record of Peak Flows
Record of Medication Use Overuse of Reliever identified Prompt Doctor review of Controller
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GINA / ICGP Guidelines
Part 1: Risk Factor Reduction
Part 2: Guided Self Management
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2: Guided Self Management
Educate
Motivate
Set Goals
Teach Self-Monitor
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Education
Currently Nurse Based
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Education
Currently Nurse Based
Expensive
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Education
Currently Nurse Based = Expensive
App- based Audio -Text tutorials
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Education
Currently Nurse Based = Expensive App- based Audio -Text tutorials
App-linked YouTube based Video Tutorials
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Education
Currently Nurse Based = Expensive App- based Audio -Text tutorials
App-linked YouTube based Video Tutorials Once viewed 5 times and Simple Question Test
Answered then....
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Education
Currently Nurse Based = Expensive App- based Audio -Text tutorials App-linked YouTube based Video Tutorials
Short –Ax by Nurse to test understanding
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2: Guided Self Management
Educate Interactive Audio-Visual- Text Lessons
Motivate
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Motivate
Currently ad Hoc Doctor/Nurse visit based
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Motivate
Currently ad Hoc Doctor/Nurse visit based
Time consuming and requires frequency
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Motivate
Currently ad Hoc + Time Consuming
Apps can automate process
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Motivate
Currently ad Hoc + Time Consuming Apps can automate process
Traffic-Light Visual Feedback to emphasis progress
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Motivate
Currently ad Hoc + Time Consuming Apps can automate process Traffic-Light Visual Feedback to emphasis
progress
Vary Frequency according to Control Status
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2: Guided Self Management
Educate Motivate
Red/Yellow/Green Visual Display Feedback
Set Goals Personal Best Metric (Frequent/Best PF etc)
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2: Guided Self Management
Educate Motivate Set Goals
Teach Self-Monitor Reminders to Fill out Symptoms Score Sheets
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2. Guided Self Management
Written Action Plan Currently Paper Based
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Example Of Contents Of An Action Plan To Maintain Asthma Control
Your Regular Treatment: 1. Each day take ___________________________ 2. Before exercise, take _____________________
WHEN TO INCREASE TREATMENTAssess your level of Asthma ControlIn the past week have you had: Daytime asthma symptoms more than 2 times ? No Yes Activity or exercise limited by asthma? No Yes Waking at night because of asthma? No Yes The need to use your [rescue medication] more than 2 times? No Yes If you are monitoring peak flow, peak flow less than________? No YesIf you answered YES to three or more of these questions, your asthma is uncontrolled and you may need to step up your treatment.
HOW TO INCREASE TREATMENTSTEP-UP your treatment as follows and assess improvement every day:____________________________________________ [Write in next treatment step here] Maintain this treatment for _____________ days [specify number]
WHEN TO CALL THE DOCTOR/CLINIC.Call your doctor/clinic: _______________ [provide phone numbers]If you don’t respond in _________ days [specify number]______________________________ [optional lines for additional instruction]
EMERGENCY/SEVERE LOSS OF CONTROLIf you have severe shortness of breath, and can only speak in short sentences,If you are having a severe attack of asthma and are frightened,If you need your reliever medication more than every 4 hours and are not improving.1. Take 2 to 4 puffs ___________ [reliever medication] 2. Take ____mg of ____________ [oral glucocorticosteroid]3. Seek medical help: Go to _____________________; Address___________________ Phone: _______________________4. Continue to use your _________[reliever medication] until you are able to get medical help.
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2. Guided Self Management
Written Action Plan Currently Paper Based
Frequently ends up under the Fridge.
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2. Guided Self Management
Written Action Plan = Lost to Fridge
App based Written action Plan
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2. Guided Self Management
Written Action Plan = Lost to Fridge
App based Written action Plan
Personalised
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2. Guided Self Management
Written Action Plan = Lost to Fridge App based Written action Plan
Personalised
Individualised
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2. Guided Self Management
Written Action Plan = Lost to Fridge App based Written action Plan
Personalised Individualised
Prompt use and indicate adequacy of adherence/control
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2. Guided Self Management
App based Written action Plan Personalised Individualised Prompt use and indicate adequacy of
adherence/control
Warn re: early Loss of Control and Advise Action
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GINA / ICGP Guidelines
Part 1: Risk Factor Reduction Part 2: Guided Self Management
Part 3: Assess – Treat- Monitor
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3. Assessing Control
Control Based on Peak Flow data Medication use Symptom Score
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3. Assessing Control
App = Power tool to Assess and Score Control
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3. Assessing Control
App = Power tool to Assess and Score Control
App = Prompt Algorithm based Action
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3. Assessing Control
App = Power tool to Assess and Score Control
App = Prompt Algorithm based Action
App = Reviewable Electronic ‘Asthma Diary’
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Apps in Other Chronic Diseases
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Apps in Other Chronic Diseases
Heart Failure
Educate re Decompensation Prompt Recording of Early Symptoms
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Apps in Other Chronic Diseases
Heart Failure Educate re Decompensation Prompt Recording of Early Symptoms
Track Daily Weights, Medication Compliance Alert Doctor to deviation or deterioration
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Apps in Other Chronic Diseases
Heart Failure
COPD Similar to Asthma
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Apps in Other Chronic Diseases
Diabetes
Education Prompt BSL Recording
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Apps in Other Chronic Diseases
Diabetes Education Prompt BSL Recording
Calorie Counting Key Metric control
BP Recording Urine Dipstick
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Penultimately
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Penultimately
Selection of My Favourite Health Apps
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Selection of Current Medical App
Asthma Coach- Asthma Society Ireland
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Selection of Current Medical App
Asthma Coach- Asthma Society Ireland
Spinal Pro III
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Selection of Current Medical App
Asthma Coach- Asthma Society Ireland Spinal Pro III
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Selection of Current Medical App
Asthma Coach Asthma Society Ireland
Spinal Pro III 3D4Medical.com
COPD Tracker Everyday Health
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For The Times They Are A-Changin’
Come gather ‘round peopleWherever you roamAnd admit that the waters
Around you have grown............If your time to youIs worth savin’
Then you better start swimmin’Or you’ll sink like a stone