ARIA Phase 4 (2018): Change management in allergic rhinitis and asthma multimorbidity using mobile technology

Abbreviations

AHA: Active and healthy ageing AIRWAYS ICPs: Integrated care pathways for airway diseasesAIT: Allergen immunotherapyAR: Allergic rhinitisARIA: Allergic Rhinitis and its Impact on AsthmaCDSS: Clinical decision support systemCM: Change managementCM2: Second phase of change managementDG CONNECT: Directorate General for Communications Networks, Content & TechnologyDG Santé: Directorate General for Health and Food SafetyDG: Directorate GeneralEAACI: European Academy of Allergy and Clinical ImmunologyEFA: European Federation of Allergy and Airways Diseases Patients’ Associations EIP on AHA: European Innovation Partnership on Active and healthy ageing EIP: European Innovation PartnershipELF: European Lung FoundationEQ-5D: EuroquolERS: European Respiratory SocietyEUFOREA: European Forum for Research and Education in AllergyGARD: WHO Global Alliance against Chronic Respiratory DiseasesHCP: Health care professionalICP: Integrated care pathwayIT: Information technologyJA-CHRODIS: Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life CycleMACVIA-LR: contre les MAladies Chroniques pour un VIeillissement Actif (Fighting chronic diseases for AHA)MASK: MACVIA-ARIA Sentinel networkmHealth: mobile healthOTC: Over the counterPOLLAR: Impact of air POLLution on Asthma and RhinitisQOL: Quality of lifeSCUAD: Severe chronic upper airway diseaseSDM: Shared decision makingTRL: Technology Readiness levelVAS: Visual analogue ScaleWHO: World Health OrganizationWPAI-AS: Work Productivity and Activity questionnaire

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Introduction

Allergic rhinitis (AR) is the most common chronic disease worldwide. Guidelines have improved the knowledge on rhinitis and made a significant impact on AR management. However, many patients are unsufficiently controlled and the costs for society are enormous, in particular due to AR major impact on school and work productivity 1. Unmet needs have clearly identified many gaps.

Allergic Rhinitis and its Impact on Asthma (ARIA) has evolved from a guideline using the best approach 2-6 to care pathways using mobile technology in AR and asthma multimorbidity 7. ARIA appears to be close to the patient’s needs but real life data obtained using an App in 22 countries have shown that very few patients use guidelines and that they often self-medicate (Bousquet, in preparation). Moreover, patients largely use OTC medications dispensed in pharmacies 8-10. Shared decision making (SDM) centered around the patient should be used more often.

ARIA has followed a change management (CM) strategy but a new one should be considered to fill the gaps in order to increase the benefits of self-medication and SDM in care pathways using the currently-available IT tools 11. These changes should prepare and support individuals, teams and organizations in making organizational change centered around the patient.

1- Background

1-1- The four ARIA phases

ARIA was initiated during a World Health Organization (WHO) workshop in 1999 (published in 2001) and has evolved in four phases (Figure 1):

Phase 1: Development of an evidence-based document to provide a guide for the diagnosis and management of AR and asthma multimorbidity including developing countries 2,3. It was implemented by the WHO Collaborating Center for Asthma and Rhinitis (Montpellier). In 2008, ARIA was updated using the same recommendation system 2,12. ARIA has been disseminated and is implemented in over 70 countries around the world 13.

Phase 2: In its 2010 Revision, ARIA was the first chronic respiratory disease guideline to adopt the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach, an advanced evidence evaluation methodology 4-6.

Phase 3: ARIA focussed on the implementation of emerging technologies for individualized and predictive medicine to develop care pathways for the management of AR and asthma by a multi-disciplinary group which included patients 14-20 (MASK: MACVIA (Contre les MAladies Chroniques pour un VIeillissement Actif)-ARIA Sentinel Network).

The next phase is change management. The aim of the novel ARIA approach is to provide an active and healthy life to rhinitis sufferers and to those with asthma multimorbidity across the life cycle whatever their sex or socio-economic status in order to reduce health and social inequities incurred by the disease.

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Figure 1: The 4 Phases of ARIA

1-2- Shared decision making and patient empowerment

In SDM, both the patient and the physician contribute to the medical decision-making process, placing the patient at the center of their decision 21. Physicians explain treatments and alternatives to patients who can then choose the treatment option that best aligns with their personal beliefs and goals along with the benefits and risks 22. In contrast to SDM, the traditional medical care system places physicians in a position of authority, with patients playing a passive role in care 23. While some physicians maintain that patients cannot make their own health care decisions, patients want greater involvement in SDM 24. An innovation of SDM is the use of IT evidence-based tools, known as patient decision aids 25.

1-3- Change management

Change is inevitable in health care. However, most change projects fail because of poor planning, unmotivated staff, deficient communication, or excessively frequent changes 26. 

According to Wikipedia (https://en.wikipedia.org/wiki/Change_management), change management (CM) is a collective term for all approaches to preparing and supporting individuals, teams and organizations in making organizational change. It includes methods that redirect or redefine the use of

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resources, business processes, budget allocation and/or modes of operation. CM significantly changes healthcare and its organization. It deals with different disciplines from healthcare, behavioral and social sciences to IT and business solutions.

Although theories may seem abstract and impractical for healthcare practice, they can help to solve common healthcare problems 26. The 3-Step model of the Lewin's approach 27 dominated the CM theory and practice for over 50 years. However, although criticized, it is still used 28,29 and has great interest in its simplicity 30. The model posits the 3-step sequence of change: unfreezing, moving, and refreezing 29,31 Lippitt 32 and  Kotter 11 have added to the collective change knowledge to expand upon Lewin’s original Planned Change Theory (Table 1) 26. 

Table 1: Examples of planned change management models. Adapted from 29

Lewin 27 Kotter 11 Lippitt 32

Unfreezing

Step 1: Establish a sense of urgency Phase 1: Diagnose the problem

Phase 2: Assess motivation and capacity for change

Step 2: Create a guiding coalition Phase 3: Assess change agent’s motivation and resources

Step 3: Develop a vision and strategy

Moving

Step 4: Communicate the change vision Phase 4: Select a progressive change objective

Step 5: Empower others to act on the vision

Step 6: Generate short-term wins

Phase 5: Choose appropriate role of the change agent Step 7: Consolidate gains and produce more change

Refreezing Step 8: Anchor new approaches in the culture and institutionalize the changes Phase 7: Terminate the helping relationship

Several models of organizational and personal change (including Kotter 11) have been reviewed for respiratory diseases 33. Kotter’s theory has been applied to different fields of medicine 34-36 and pharmacies 37.

2- ARIA Phases 1 and 2 follow the Kotter’s 8-step change model

2-1- Goals

Guidelines such as GINA (Global initiative for Asthma) 38,39, GOLD (Global initiative for Lung Diseases) 40,41 or ARIA 3,4,12 were developed from the 1990’s in order to better manage asthma, COPD or AR. All these three initiatives developed a CM strategy that was very effective and produced many updates and revisions.

However, ARIA was unique as it included for the first time the multimorbid component of the airway diseases. Although it followed the patient’s perpectives, epidemiologic evidence 42,43 and some supporting mechanistic studies 44,45, this concept was not accepted by the leadership of GINA who denied the asthma-rhinitis multimorbidity concept and benefit for the patients.

2-2- The 8-step model

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2-2-1- Establish a sense of urgency

The sense of urgency should identify and highlight the potential threats and the repercussions that might crop up in the future by examining the opportunities which can be tapped through effective interventions. In AR and asthma, in the 1990’s the sense of urgency was to provide guidelines that could reduce the burden of the diseases and deaths (in asthma).

2-2-2- Create a guiding coalition

The ARIA working group was initiated during a WHO meeting (December 1999) and has evolved as a powerful group with 400 members in 70 countries in 2012 13. Members have been working together for years and include all stakeholders needed for CM 2-7. The patient’s organization EFA (European Federation of Allergy and Airways Diseases Patients’ Associations) has always been a solid member of ARIA.

2-2-3- Develop a vision and strategy

The ARIA vision has always been to provide a guide for the diagnosis and management of AR and asthma multimorbidity including developing countries 2,3 using the best evidence 4-6. ARIA has established two major targets: the recognition and implementation of the asthma-rhinitis multimorbidity and a new classification (intermittent-persistent and mild-moderate severe AR) to meet patient’s expectations. Moreover, ARIA priorities always included primary care physicians, pharmacists and patient’s organizations.

2-2-4- Communicate the change vision

One of the ARIA strengths has been to communicate its vision powerfully and convincingly worldwide. Over 1,000 papers have been posted on Pubmed from over 50 countries using the ARIA recommendations 13. The number of training sessions in over 70 countries cannot be counted. ARIA was endorsed by many governments and international organizations and ARIA recommendations have been used for the labeling of allergen immunotherapy.

2-2-5- Empower others to act on the vision

Organizational processes and structures are in place and are aligned with the overall organizational vision. However, we need to continuously check for barriers and for people who are resisting change. We have always been implementing proactive actions to remove the obstacles involved in the process of change.

ARIA has been recognized as the major rhinitis and asthma multimorbidity guideline for years in most countries except for the US and Japan. However, the recent US guidelines are using the evidence-based approach of ARIA (GRADE: Grading of Recommendations, Assessment, Development and Evaluation) and recommendations are similar 46-48 to those of ARIA 6. The recent Japanese guidelines for AR are also making bridges with ARIA 49.

2-2-6- Generate short-term wins

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As proposed by Kotter 11, creating short-term wins early in the change process can give a feel of victory in the early stages of change instead of one long-term goal.

The concept of asthma and rhinitis multimorbidity is now globally accepted without any doubt in developed and developing countries 50. It is now recognized that multimorbidity is independent of IgE-mediated allergy 51,52 and new phenotypes of severe airway diseases have been identified. The implementation of the multimorbid concept in clinical practice has a direct benefit for the patient for whom nasal symptoms are often more bothersome than asthma.

2-2-7- Consolidate gains and produce more change

The goals of step 7 11 are to achieve continuous improvement by analysing the success stories individually and improving from those individual experiences. These goals are exactly those followed by ARIA for the past 18 years..

2-2-8- Anchor new approaches in the culture and institutionalize the changes

The goals of step 8 11 are met by the ARIA strategy:

1. Discuss the successful stories related to change initiatives widely.2. Ensure that the change becomes an integral part of the practice and is highly visible.3. Ensure that the support of the existing as well as the new leaders continues to extend towards the

change.

2-3- Drawbacks and solutions

Some drawbacks have been pointed out in the Kotter’s change model 11. In particular, the model is essentially top-down and may discourage any scope for participation or co-creation. In ARIA, we considered that the first CM model was a great success but the life cycle had come to an end. It was then decided within the coalition to propose a new CM model based on patient’s needs and emerging technologies. Since the Kotter’s model cannot be redesigned, we proposed a new maturity CM model based on the same Kotter’s 8-step change model 11. We used ARIA Phase 3 (care pathways for rhinitis and asthma multimorbidity using mobile technology) 7 to better understand the CM2 model and make new assumptions with a patient’s centered approach.

3- The Allergy Diary strengthens change management

3-1- MASKIn 2012, the European Commission launched the European Innovation Partnership on Active and Healthy Ageing (DG Santé and DG CONNECT) 53. The B3 Action Plan devoted to innovative integrated care models for chronic diseases has selected Integrated care pathways for airway diseases (AIRWAYS ICPs) 54,55 with a life cycle approach 56 as the model of chronic diseases. AIRWAYS ICPs Action Plan has been devised 54, implemented 57 and scaled up 58,59. AIRWAYS ICPs is a GARD (WHO Global Alliance for Chronic Respiratory Diseases) 60 research demonstration project (Figure 3).

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Figure 3: Links between ARIA and MASK for change management

CC: Collaborating Center, GA2LEN: Global Allergy and Asthma European network, GARD: Global Alliance against Chronic Respiratory Diseases, MeDALL: Mechanisms of the Development of Allergy, SPAL:, Sunfrail, POLLAR: Impact of air pollution in asthma and rhinitis.

MASK (MACVIA-ARIA Sentinel Network), the ARIA Phase 3, is an AIRWAYS ICPs tool 7,61. It represents a Good Practice focusing on the implementation of multi-sectoral care pathways using emerging technologies with real life data in rhinitis and asthma multi-morbidity. MASK follows the JA-CHRODIS (Joint Action on Chronic Diseases and Promoting Healthy Ageing across the Life Cycle, 2nd EU Health Programme 2008-2013 62) recommendations for good practices 18.

MASK was initiated to reduce the global burden of rhinitis and asthma, by giving the patient a simple tool to better prevent and manage respiratory allergic diseases. More specifically, MASK should help to (i) understand the disease mechanisms and the effects of air pollution in allergic diseases (ii) better appraise the burden incurred by medical needs but also indirect costs, (iii) propose novel multidisciplinary care pathways integrating pollution and patient's literacy, (iv) improve work productivity, (v) propose the basis for a sentinel network at the EU level for pollution and allergy and (vi) assess the societal implications of the project to reduce health and social inequalities globally.

3-2- The Allergy Diary

The mobile technology of MASK is the Allergy Diary, an App (Android and iOS) freely available for AR and asthma sufferers in 23 countries (16 EU countries, Argentina, Australia, Brazil, Canada, Mexico, Switzerland and Turkey) and 16 languages (translated and back-translated, culturally adapted and legally compliant) 7. Anonymized users fill in a simple questionnaire on asthma and rhinitis upon registration and assess daily the impact of the disease using a visual analogue scale (VAS) 63 for global allergy symptoms, rhinitis, conjunctivitis, asthma and work. Moreover, a questionnaires is applied every week to assess disease impact on patients’ QOL (EQ-5D) 15.

Pilot studies in up to 17,000 users and over 95,000 days are available. The Allergy Diary has been validated 64 and has shown that (i) totally anonymized geolocation can be used in 22 countries (in preparation), (ii) data can be analyzed in 22 countries and 16 languages, (iii) sleep, work productivity and daily activities are impaired in AR 15,17, (iv) daily work productivity is associated with AR severity 16, (v) everyday use of medications can be monitored proposing a novel assessement of treatment

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patterns (in press), (vi) novel patterns of multimorbidity have been identified (submitted) and confirmed in epidemiological studies 52,65 and (vii) over 80% of AR patients self-medicate and are non-observant (Menditto, in preparation).

The Allergy Diary (TLR 9, Technology Readiness level) represents a validated mHealth tool for the management of AR. Asthma has also been monitored but data have not yet been analyzed. Economic impact can be monitored using work productivity. The results of the Allergy Diary have made innovative approaches of AR possible and are directly strengthening CM strategies in ARIA.

3-3- Transfer of Innovation of MASK

A Transfer of Innovation (Twinning) has been funded by the EIP on AHA using MASK in 22 Reference Sites or regions across Europe, Australia, Brazil and Mexico 14. This will improve the understanding, assessment of burden, diagnosis and management of rhinitis in old age by comparison with an adult population. The Twinning has been tested in Germany (Region Kohl-Bohn) in a pilot study that has now been extended to the other countries of the Twinning.

3-4- Clinical decision support system

Clinical decision support systems (CDSS) are software algorithms that advise health care providers on the diagnosis and management of patients based on the interaction of patient data and medical information. They should be based on the best evidence to aid patients and health care professionals to jointly determine the treatment (SDM). In allergic rhinitis, the MASK CDSS is incorporated into a tablet interoperable with the Allergy Diary 66 for health care professionals (ARIA Allergy Diary Companion) 7,61. This is based on an algorithm to aid clinicians to select pharmacotherapy for AR patients and to stratify their disease severity 67.

3-5- POLLAR

Interactions between air pollution, sleep and allergic diseases are clear but insufficiently understood. POLLAR (Impact of Air Pollution in Asthma and Rhinitis) is a new Horizon 2020 project of the EIT Health (European Institute of Innovation and Technology for Health) that will embed environmental data into the Allergy Diary. POLLAR aims at combining emerging technologies (including Allergy Diary, Technology Readiness level TLR9) with machine learning to (i) understand the effects of air pollution in AR and its impact on sleep, work, asthma, (ii) assess societal consequences, shared with citizens, corporate citizens and professionals (iii) propose preventive strategies including a sentinel network and (iv) develop participative policies.

4- ARIA Phases 3 and 4 deploy a novel Kotter’s 8-step change model

4-1- Goals

Although the first CM model was a great success, there are still unmet needs in the treatment of asthma and rhinitis multimorbidity. In ARIA Phase 4, we encourage participation of all the stakeholders. As an example, all proposals for unmet needs (Table ) and short term targets (Table) were discussed using a Delphi and MonkeySurvey by the members of the CM coalition and will be reviewed every year to assess the achievements, make eventual corrections and propose new targets. Moreover, all comments from MASK members and others are considered carefully.

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4-2- The 8-step model

4-2-1- Establish a sense of urgency

ARIA has established a sense of urgency over its 18-year development and has achieved many results. However, some gaps still exist and a list of priorities has been established by the ARIA expert group using a Delphi process followed by a Survey Monkey (Table 2 and online supplement 1). LIST TO BE DISCUSSED

Name:

Table 2: Gaps in the knowledge of rhinitis and asthma multimorbidity

Current gaps Priority (0-10)

Comments

1 A large number of AR patients do not consult a physician 68,69. They self-manage 9 with little interaction with their health care professionals about their allergy prescription 69. Self-management has never been rigorously approached in an AR guideline or care pathway. However, the impact of a physician on AR control is still unclear and needs more studies 70,71. Self-management may be improved using IT 72,73.

2 Few AR patients have a physician’s AR diagnosis 68,74 and few consulting in primary care have a diagnosis of allergy 75,76.

3 Many AR patients use over the counter (OTC) drugs 8-10,77-80. In many countries, the pharmacist is at the forefront of AR management 77. The vast majority of patients who visit GPs or specialists have moderate/severe rhinitis 81-84 but this appears to also be the case in pharmacies 68,85.

4 A large number of OTC or prescribed drugs are available for the patient who can also choose alternative medicine or allergen specific immunotherapy 86. SDM and precision medicine 87,88 should be combined.

5 AR treatment is based on concepts that do not necessarily apply to real life. All recommendations propose a continuous treatment rather than an on-demand use. Adherence to treatment is low 89,90 (Menditto et al, in preparation). New technologies using several methods 91 including short message sending may increase adherence 92,93. The relative efficacy of continuous versus on-demand treatment for AR symptoms is still a matter of debate 94,95. In particular, intranasal corticosteroids are indicated by regulatory agencies and prescribed by physicians for a regular long-term use although there is no evidence that this is more effective than on-demand use 95. Moreover, in real life, patients rarely follow guidelines (Menditto et al, in preparation).

6 Adherence ot treatment is a concept that may be revised 93,96-98.

7 There is a very long time span between the first symptoms experienced by patients and appropriate treatment. The role of patients is essential in this process to reduce the time from first symptoms to optimal treatment.

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8 Although ARIA was initiated almost 20 years ago and multimorbidity of rhinitis and asthma is fully accepted 99, many patients do not yet have an assessment of the upper and lower airways.

9 It is evident that aerobiology should be embedded in care pathways, but there is no guideline or care pathway in AR including pollen counts and pollution data.

10 There are wide differences in allergen immunotherapy (AIT) around the world, and many regulatory authorities are discussing the reimbursement of AIT. There is a need for appreciation of cost-effectiveness of AIT using approved forms of treatment (e.g. tablets for SLIT) but also for NPPs (name patient product) using real-life data 100.

Add

Priority (0 useless-10 very useful) to be added by a Survey Monkey

ICPs will consider multi-disciplinary structured care plans detailing the key steps of patient care including self-management as proposed by AIRWAYS ICPs 54 (Integrated care pathways for airway diseases, Figure 3).

Figure 3: Care pathways for allergic rhinitis and asthma multimorbidity (From 54)

4-2-2- Create a guiding coalition

The ARIA working group was initiated in 1999 and includes over 500 members in 70 countries 13. A powerful coalition working on CM2 has been identified within the ARIA group.

The AIRWAYS ICPs coalition was established in 2014 and is part of the European Innovation Partnership on Active and Healthy Ageing (DG Santé and DG CNECT) 54. Moreover, many national and European scientific societies (European Academy of Allergy and Clinical Immunology EAACI, European Respiratory Society ERS and International Primary Care Respiratory Group IPCRG), and another patient’s organization (European Lung Foundation (ELF)) have joined the coalition. It is a WHO GARD (WHO Global Alliance against Chronic Respiratory Diseases) demonstration project.

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Finally, the transfer of innovation of ARIA has been carried out to the Reference Sites of the European Innovation Partnership on Active and Healthy Ageing 14.

This CM2 guiding coalition is already in place in EUFOREA (European Forum for Reasearch and Education in Allergy and Airways Diseases, http://www.euforea.eu) 101.

4-2-3- Develop a vision and strategy

From 1999, the ARIA vision was to provide a guide for the diagnosis and management of AR and asthma multimorbidity including developing countries 2,3 using the best evidence 4-6. ARIA Phase 3 focussed on the implementation of emerging technologies for individualized and predictive medicine to develop care pathways for the management of rhinitis and asthma by a multi-disciplinary group which included patients 14-20. The vision of ARIA phase 4 is to provide CM2 for AR and asthma multimorbidity in order to develop SDM with the ultimate goal of improving AR and asthma control while maintaining quality-of-life and reducing costs.

The strategy for realizing the changes is based on the patient-centered implementation of ICPs 54 using IT solutions such as the Allergy Diary 7.

4-2-4- Communicate the change vision

The updated vision (CM2) will use the experience of the first CM strategy. It has already been discussed among the ARIA CM coalition members and the present paper is the first to be published. However, it takes time to handle the concerns of certain people, and the papers published recently on the Allergy Diary may help to convince many. We are involving a maximum number of people to deploy our CM vision.

4-2-5- Empower others to act on the vision

Organizational processes and structures are in place and are aligned with the overall organizational vision. However, we need to continuously check for barriers and for people who are resisting change. We are implementing proactive actions to remove the obstacles involved in the process of change.

4-2-6- Generate short-term wins

We propose to create new short-term targets. To confirm the sense of urgency in AR and asthma multimorbidity, XX questions can be approached as a first step.

LIST TO BE DISCUSSED

Name:

Short term targets Priority

Action plan Comment

1 Real life approach of AR treatment

The follow up of MAS will provide a better assessment of the management of AR and asthma in real life. It is expected that 50,000 users (500,000

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days) can be analyzed at the end of 2018

2 Self-management of AR and asthma multimorbidity

With patient’s organisations (EFA, ELF and others), a proposal for self-management should be discussed. The results of PROSTEP (EU proposal ending October 2017) should be included

3 Management of AR and asthma multimorbidity in the pharmacy

The 2004 ARIA in the pharmacy is currently being revised to integrate the role of the pharmacist in ICPs

4 SDM in AR care pathways ARIA ICPs with self-medication and the pharmacist role, embedding aerobiology with a focus on SDM, will be developed by POLLAR (end 2018)

5 Inclusion of aerobiology data in guidelines and care pathways

6 Real-life observational studies of AIT

MASK is able to assess the real life effectiveness of AIT

7 AR and asthma in old age addults

AR and asthma affect over 20% of the old age population but they are poorly understood. The Twinning project will improve our knowledge and allow to provide ICPs.

8 In POLLAR, a consensus meeting is planned at the end of 2018 to propose ICPs for asthma and rhinitis including aerobiology and patients’ views obtained by m-Health including the Allergy Diary.ADD

Priority (0 useless-10 very useful)

4-2-7- Consolidate gains and produce more change

The goals of the Kotter’s change model step 7 11 are exactly those followed by ARIA CM and CM2 will build on existing gains.

4-2-8- Anchor new approaches in the culture and institutionalize the changes

The goals of the Kotter’s change model step 8 11 are mostly met by the ARIA CM and will be developed in CM2.

4-3- Indicator of success

The DICE framework (Duration, Integrity, Commitment and Effort) was used as an indicator of likely success of CM2 102. A score of 9 was calculated (Duration: average time between reviews: 4 months, score 3, Team performance integrity: very good, score 1 x 2, Commitment of the senior management:

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clear, score 1 x 2, Local commitment: eager, score 1, effort <10% additional, score 1). This score falls in the “win” zone (very likely to succeed: score from 7 to 14).

Conclusions

For the past 18 years, ARIA had the major goal to provide a guide for the diagnosis and management of AR and asthma multimorbidity including developing countries 2,3 using the best evidence 4-6. ARIA Phases 1 and 2 were developed using the Kotter’s 8 step change model and can be used as a model of CM in chronic diseases. However, there are still unmet needs for the management of rhinitis and asthma in real life.

A second CM model has been proposed by ARIA Phases 3 and 4. It was initiated by the development in 23 countries of an App that showed partly unexpected results. Patients with AR (and possibly with asthma) do not follow physician’s advices and self-medicate. There is an urgent need to update our concept of treatment using mobile technology and care pathways. This is the goal of ARIA Phase

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