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May 21 2012

What do mHealth, eHealth and behavioral science mean for the future of healthcare?

We're living through one of the most dynamic periods in healthcare in our collective history. Earlier this year, Dr. Farzad Mostashari, the national coordinator of health IT, highlighted how the web, data and epatients are poised to revolutionize healthcare. The Internet is shaping healthcare in many ways, from the quantified self movement to participatory medicine, and even through the threat of a new "data divide" driven by unequal access to information, algorithmic and processing power.

Dr. Audie AtienzaInto this heady mix, add the mobile computing revolution, where smart devices rest in the pockets of hundreds of millions of citizens, collecting data and providing access to medical information. There's also the rapidly expanding universe of healthcare apps that promise to revolutionize how many services are created, distributed and delivered.

This month, I had the opportunity to discuss some of these trends with Dr. Audie Atienza (@AudieAtienza), a researcher who focuses on behavioral science and healthcare. Our interview, lightly edited for content and clarity, follows.

We first met when you were a senior health technology adviser at the U.S. Department of Health and Human Services (HHS). What do you do now?

Audie Atienza: Working with Todd Park at the Department of Health and Human Services (HHS) was a distinct privilege and an honor. I learned a great deal working at HHS with Todd. I am now at the new Science of Research and Technology Branch of the National Cancer Institute, National Institutes of Health.  My title is Behavioral Scientist and Health Scientist Administrator. In a typical week, I attend health-technology-related conferences and meetings, work with colleagues across HHS and the federal government on health-technology-related initiatives, discuss funding opportunities with extramural researchers, and engage in scientific research related to health technology and/or cancer control.

How well did your education prepare you for your work?

Audie Atienza: My undergraduate, graduate and post-doctoral education has provided me with the critical thinking skills and knowledge that is required of a health researcher. My interest in health technology actually started when I was a Fellow at Stanford University, where I was gathering data on cardiovascular disease risk factors using paper and pencil diaries.  Using paper and pencil measures seemed so inefficient. Study participants sometimes forgot to complete the diaries or had incomplete entries — and sometimes the handwriting was difficult to decipher.  So, my mentor, Dr. Abby King, and I collaborated with Dr. BJ Fogg (also at Stanford) and we "went digital" with the cardiovascular disease risk factor assessments. (We used "state of the art" PDAs at the time.)  This fortuitous collaboration and the "there has to be a better way to do this" idea launched me into the field of electronic and mobile health.

What does "eHealth" mean now?

Audie Atienza: After my postdoctoral fellowship at Stanford, I accepted a position at the National Cancer Institute (NCI), Health Promotion Research Branch.  The NCI offered me the opportunity to further explore the field of electronic health (or eHealth) on a national (U.S.) and international scale.  The term "eHealth" generally represents the use of electronic or digital information technology to assess and/or modify health behaviors, states and outcomes.

When I arrived at NCI, I was asked to bring the best and brightest behavioral researchers together to discuss how to assess health in "real-time."  A book was published based on this meeting: "The Science of Real-Time Data Capture Self-Reports in Health Research." Other national and international conferences followed, including the 2010 mHealth Summit, in which I was intimately involved.

How does behavioral science affect our capacity to understand the causes of cancer?

Audie Atienza: It is clear that behavioral factors contribute to cancer and many other diseases, like diabetes and heart disease.  For example, the link between smoking and cancer is well established. There is also a solid body of research that has linked obesity, physical inactivity, and poor diet to various cancers. The Centers for Disease Control (CDC) reports that 69% of U.S. adults are currently overweight or obese.[Data on adults: PDF and children: PDF]

Accurately measuring and changing these everyday health behaviors — including smoking, physical activity, what people eat — is not easy. This is where technology can be of great assistance. Through sensors, cell phones, GPS systems, social networking technology, and web-based technology, we may be able to better assess and hopefully improve these key health behaviors that contribute to cancer and other diseases.

We are, however, just at the beginning of discovering how to best develop and utilize technology to improve the health of individuals and the public.  There is much work to be done to determine what is effective and what isn't.

How do mobile devices figure into that work?

Audie Atienza: Mobile technology is everywhere. We are seeing more integrated devices, like smartphones with cameras, accelerometers, GPS, and all types of apps.  But it isn't about the technology — a phrase I have borrowed from Todd Park. It's really about addressing health issues and improving the health of individuals and the public.  If technology can facilitate this, then great. But using technology may not always be the best way to improve health and well-being.  This is a critical research question.

How is mobile technology being applied to specific health issues?

Audie Atienza: Mobile technology can be (and is being) applied to address many different health and disease issues: infection disease (AIDS/HIV, tuberculosis, influenza), chronic disease (heart disease, cancer, diabetes, arthritis, asthma), mental health (depression, stress, anxiety), child and maternal health (pregnancy, infant care, childhood obesity), gerontology (healthy living in place, falls prevention, caregiving), health promotion (e.g., exercise, diet, smoking cessation, cancer screening, sun safety), and health-provider-related issues (medication adherence, patient-provider communication, point-of-care diagnostics, vital signs monitoring).

Mobile technology cuts across the disease and health spectrum with great potential to address problems that have been previously difficult to solve.  It is difficult to say which mobile health technology is most important because they are all addressing distinct and critical issues.  Heart disease and cancer are the leading causes of death in the United States. Others may argue that infectious diseases and maternal/child health are the most critical issues to address globally. Still others may argue for tobacco control and reducing obesity (increasing physical activity and improving nutrition).  The National Institutes of Health (NIH) has 27 institutes and centers (ICs), each with a particular mission.  More than 20 of the 27 ICs are currently funding mobile technology-related research.

What do we need next in mHealth?

Audie Atienza: More research. We need to better understand what works and what does not. Researchers who have systematically reviewed smartphone health apps (e.g., smoking cessation, diabetes) have found that most are not based on established public health or clinical guidelines. Very few have actually assessed whether the apps are effective in changing health outcomes. With thousands of apps, sensors, and other mobile health tools currently available, it can be difficult for the user to know what is effective, useful, and (most importantly) safe.

How close are we to a real tricorder? (There's now an X Prize for that.)

Audie Atienza: I love science-fiction and "Star Trek"!  Certainly, mobile sensors and monitors currently exist that can accurately monitor physiological states and vital signs. And the technology is becoming increasingly integrated and more powerful.  But, to have an all-in-one mobile device that can assess and diagnose health and diseases as well as, if not better than, a clinical provider is a very tall order. If such a tool or prototype is developed, it will be science and research that will determine if the "tricorder" is effective or not.  Time will tell whether such a tool can be developed.  While I am all for reducing diagnostic errors, I personally would be hesitant to accept a diagnosis from only a mobile device without the clinical judgment of a medical or health professional.

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February 21 2012

Building the health information infrastructure for the modern epatient

To learn more about what levers the government is pulling to catalyze innovation in the healthcare system, I turned to Dr. Farzad Mostashari (@Farzad_ONC). As the National Coordinator for Health IT, Mostashari is one of the most important public officials entrusted with improving the nation's healthcare system through smarter use of technology.

Dr. Farzad MostashariMostashari, a public-health informatics specialist, was named ONC chief in April 2011, replacing Dr. David Blumenthal. Mostashari's full biography, available at HHS.gov, notes that he "was one of the lead investigators in the outbreaks of West Nile Virus and anthrax in New York City, and was among the first developers of real-time electronic disease surveillance systems nationwide."

I talked to Mostashari on the same day that he published a look back over 2011, which he hailed as a year of momentous progress in health information technology. Our interview follows.

What excites you about your work? What trends matter here?

Farzad Mostashari‏: Well, it's a really fun job. It feels like this is the ideal time for this health IT revolution to tie into other massive megatrends that are happening around consumer and patient empowerment, payment and delivery reform, as I talked about in my TED Med Talk with Aneesh Chopra.

These three streams [how patients are cared for, how care is paid for, and how people take care of their own health] coming together feels great. And it really feels like we're making amazing progress.

How does what's happening today grow out of the passage of the Health Information Technology for Economic and Clinical Health Act (HITECH) Act in 2009?

Farzad Mostashari‏: HITECH was a key part of ARRA, the American Recovery and Reinvestment Act. This is the reinvestment part. People think of roadways and runways and railways. This is the information infrastructure for healthcare.

In the past two years, we made as much progress on adoption as we had made in the past 20 years before that. We doubled the adoption of electronic health records in physician offices between the time the stimulus passed and now. What that says is that a large number of barriers have been addressed, including the financial barriers that are addressed by the health IT incentive payments.

It also, I think, points to the innovation that's happening in the health IT marketplace, with more products that people want to buy and want to use, and an explosion in the number of options people have.

The programs we put in place, like the Regional Health IT Extension Centers modeled after the Agriculture Extension program, give a helping hand. There are local nonprofits throughout the country that are working with one-third of all primary care providers in this country to help them adopt electronic health records, particularly smaller practices and maybe health centers, critical access hospitals and so forth.

This is obviously a big lift and a big change for medicine. It moves at what Jay Walker called "med speed," not tech speed. The pace of transformation in medicine that's happening right now may be unparalleled. It's a good thing.

Healthcare providers have a number of options as they adopt electronic health records. How do you think about the choice between open source versus proprietary options?

Farzad Mostashari‏: We're pretty agnostic in terms of the technology and the business model. What matters are the outcomes. We've really left the decisions about what technology to use to the people who have to live with it, like the doctors and hospitals who make the purchases.

There are definitely some very successful models, not only on the EHR side, but also on the health information exchange side.

(Note: For more on this subject, read Brian Ahier's Radar post on the Health Internet.)

What role do open standards play in the future of healthcare?

Farzad Mostashari‏: We are passionate believers in open standards. We think that everybody should be using them. We've gotten really great participation by vendors of open source and proprietary software, in terms of participating in an open standards development process.

I think what we've enabled, through things like modular certification, is a lot more innovation. Different pieces of the entire ecosystem could be done through reducing the barrier to entry, enabling a variety of different innovative startups to come to the field. What we're seeing is, a lot of the time, this is migrating from installed software to web services.

If we're setting up a reference implementation of the standards, like the Connect software or popHealth, we do it through a process where the result is open source. I think the government as a platform approach at the Veterans Affairs department, DoD, and so forth is tremendously important.

How is the mobile revolution changing healthcare?

We had Jay Walker talking about big change [at a recent ONC Grantee Meeting]. I just have this indelible image of him waving in his left hand a clay cone with cuneiform on it that is from 2,000 B.C. — 4,000 years ago — and in his right hand he held his iPhone.

He was saying both of them represented the cutting edge of technology that evolved to meet consumer need. His strong assertion was that this is absolutely going to revolutionize what happens in medicine at tech speed. Again, not "med speed."

I had the experience of being at my clinic, where I get care, and the pharmacist sitting in the starched, white coat behind the counter telling me that I should take this medicine at night.

And I said, "Well, it's easier for me to take it in the morning." And he said, "Well, it works better at night."

And I asked, acting as an empowered patient, "Well, what's the half life?" And he answered, "Okay. Let me look it up."

He started clacking away at his pharmacy information system; clickity clack, clickity clack. I can't see what he's doing. And then he says, "Ah hell," and he pulls out his smartphone and Googles it.

There's now a democratization of information and information tools, where we're pushing the analytics to the cloud. Being able to put that in the hand of not just every doctor or every healthcare provider but every patient is absolutely going to be that third strand of the DNA, putting us on the right path for getting healthcare that results in health.

We're making sure that people know they have a right to get their own data, making sure that the policies are aligned with that. We're making sure that we make it easy for doctors to give patients their own information through things like the Direct Project, the Blue Button, meaningful use requirements, or the Consumer E-Health Pledge.

We have more than 250 organizations that collectively hold data for 100 million Americans that pledge to make it easy for people to get electronic copies of their own data.

Do you think people will take ownership of their personal health data and engage in what Susannah Fox has described as "peer-to-peer healthcare"?

Farzad Mostashari‏: I think that it will be not just possible, not even just okay, but actually encouraged for patients to be engaged in their care as partners. Let the epatient help. I think we're going to see that emerging as there's more access and more tools for people to do stuff with their data once they get it through things like the health data initiative. We're also beginning to work with stakeholder groups, like Consumer's Union, the American Nurses Association and some of the disease groups, to change attitudes around it being okay to ask for your own records.

This interview was edited and condensed. Photo from The Office of the National Coordinator for Health Information Technology.

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Save 20% on registration with the code RADAR20

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