PDA Software to Encourage Healthy Behaviors

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PDA Software to Encourage Healthy Behaviors

• Scott M. Strayer, MD, MPH
• Assistant Professor
• University of Virginia, Dept. of Family Medicine
• Center for Information Mastery

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Outline

• The Top Unhealthy Behaviors
• How Do We Change Patient Behaviors
• Behavioral Change Theories
• PDA Software for Physicians
• PDA Software for Patients
• Building Your Own
• The Evidence

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The Top Unhealthy Behaviors

• Smoking
• Unhealthy Diet
• Excess Alcohol Intake
• Sedentary Lifestyle

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How do we change patient behavior?

• Not very well!!
• Only 20-25 of Physicians counsel on diet and
  exercise ("Direct Observation of Physician
  Counseling on Dietary Habits and Exercise
  Patient, Physician, and Office Correlates,"
  published in the journal Preventive Medicine).
• Only 35 of Physicians assist with smoking
  cessation attempts (Thorndike AN, Rigotti NA,
  Stafford RS, Singer DE. National patterns in the
  treatment of smokers by physicians. JAMA 1998
  279604-608).

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Opportunities for Intervention

• Most people visit a primary care doctor about
  three times per year.
• Even 2-3 minute interventions are effective,
  especially when followed up with telephone,
  e-mail, nurse calls, referrals, 1-800 numbers,
  etc.
• Many primary care providers provide 2-3 minute
  health promotion/behavior interventions at every
  outpatient visit.
• Stange, KC, Woolf, SH, Gjeltema K. One
  minute for prevention The power of leveraging to
  fulfill the promise of health behavior
  counseling. Am J Prev Med, 2002 22320-323.

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The other elements of brief health promotion

• Goal setting
• Specific Behavior Change Techniques
• Self-help Materials
• Regular Follow-up

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New strategies, tools and technical assistance
are needed to tailor these more complex
interventions to the realities of current primary
care practice.

• RWJ Foundation, Prescription for Health Initiative

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Behavioral Change Theories

• Stages of Change----assess patients readiness to
  change and then deliver stage-appropriate
  interventions
• Motivational Interviewing---a non-confrontational
  technique for helping patients change their
  health behavior

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Stages of Change

• Pre-contemplation
• Contemplation
• Preparation
• Action
• Maintenance

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Motivational Interviewing-DARES

• Develop Discrepancy
• Avoid Argumentation
• Roll with Resistance
• Express Empathy
• Support Self-Efficacy

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Integrating the Behavioral Theories
Smoking and BMI as Vital signs

• Ask
• Advise
• Assess
• Assist
• Arrange

Not Stage-dependent
Use Motivational Interviewing
Stages of Change Motivational Interviewing
Stage-based interventions Motivational
Interviewing
Local and national resources
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Development of the MLIT

• Operationalize the Stages of Change
• Identify stage based interventions
• Scripted motivational interviewing
• Risk calculators
• Pharmacotherapy info
• Local and national resources
• Modular design

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A Patient Success Story
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USPTF AHRQ tool
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InfoRetriever 2004 Windows 95/98/NT/ME/2000/XP,
PocketPC, Palm and Web
1800 short research synopses (400 added per year)
Cochrane Database of Systematic Reviews over
1500 abstracts
5 Minute Clinical Consult
Bayesian diagnostic test / HP calculator
140 clinical prediction rules
Basic drug info by class and cost for 1200 drugs
Key evidence-based treatment guidelines
www.InfoPOEMs.com
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InfoRetriever to help with treatment decisions

• A 46 y/o male, smoker
• PMH significant for hypertension treated with
  HCTZ. Most recent BP 138/86.
• FH Both parents have HTN over age 70, no h/o
  CAD.
• Lipids Chol 197 HDL 41 LDL 141.
• Questions
• What is his risk of an AMI or sudden cardiac
  death in the next 10 years?
• How much will lowering the SBP below 130 reduce
  the risk?
• How much will stopping smoking affect his risk?

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Should his SBP be lowered to 24
What if he quit smoking instead?
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PDA Programs for Patients
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Finding Programs

• www.pdamd.com
• www.aafp.org
• www.handango.com
• www.palmgear.com

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Smoking Cessation

• My Last Cigarette

FeaturesNicotine level readoutExpected
cravings readoutDeaths since you quit
readoutDaily motivational messageCarbon
Monoxide level of your bloodIncrease in life
expectancy readoutTime you have been a non
smoker readoutNumber of cigarettes NOT smoked
readoutYour risk of a heart attack compared to
your risk beforeYour risk of lung cancer
compared to your risk beforeExpected circulatory
improvementExpected lung function
improvementReadouts updated every second and are
based upon your own personal past
smoking habits.All calculations are based upon
the latest medical knowledge and statistics.
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Quitability

• Identify key personal motivators
• Identify triggers and how to cope with them
• Help with changing environment
• Coping with lapses

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Diet and Exercise Assistant

• Input your personal information (height, weight,
  age, gender), and the software will automatically
  calculate the calories you burn during the day.
• Establish a weight loss program by setting a
  weight loss goal, target date, and monitor
  progress with charts and graphs.  A calorie
  calculator automatically calculates the calories
  you need to remove from your diet in order to
  achieve your weight loss goals.
• In addition to setting weight loss goals, you can
  now select a diet plan, input your own diet plan,
  and set nutrient targets.  Graph your weight
  using the new weekly and monthly historic weight
  charts.  New!
• Track your nutrition by monitoring calories,
  carbohydrates, protein, fiber, fat, and saturated
  fat.  A large food database with over 8,000 food
  items is available with all of the nutrient
  information to make tracking your nutrition
  easy.  The food database is configurable you can
  add, delete, or modify any food item in the
  database.  The nutritional information label on
  the back of most products contains all of the
  information you need to add a food item to the
  food database.

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Diet Tracker by Dream Fusion

• Integrated 6000 item food database.
• 98 item exercise database.
• Your own private meal database (unlimited size)
  for rapid day to day entry.
• Both Imperial and Metric measurement systems
  supported.
• Body Mass Index calculator.
• Fast,very usable and stable.
• Compatible with all known palm OS handhelds.
• Intuitive diet diary.
• Monitor your water intake.
• Monitor your sleeping patterns and well being.
• Password protect your data.
• View daily goal graphs.
• 'Check In' area for graphing weight loss progress
  over time.
• Track progress via either your weight or waist
  size.
• Optionally track either carbohydrate (great for
  Atkins folks) or fat, in addition to Calories.

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Chronic Disease Management

• Asthma
• Diabetes
• Hypertension

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You can build your own with database programs

• www.handbase.com

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Saving Time By Downloading Others Databases
www.ddhsoftware.com/gallery
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Creating a Basic Database Using HanDBase

• Decide what you want to track.
• Determine the fields and information type you
  will require.
• How robust does it need to be?
• Does it need more than one database (i.e.
  relational)?
• Has it already been made? (you can download free
  applets from www.handbase.com)

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Building Your Own---A Quick Example
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Does it Work?
Physician performance improved (43/65) Drug
dosing systems (9/15) Diagnostic aids
(1/5) Preventive care systems (14/19) Clinical
decision support systems(19/26) Patient outcomes
improved (6/14)
JAMA, October 21, 1998. Vol 280, No. 15, pp 1339
-1346.
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Tailored Smoking Cessation Messages for Patients
Work

• Orleans CT, Boyd NR, Noll E, Crosette L.
  Intervening
• through a prescription benefit plan for nicotine
  patch
• users. Paper presented at the Society of
  Behavioral Medicine
• Annual Meeting.Washington DC, March 1996.
• Prochaska JO, DiClemente CC, Velicer WF, Rossi
  JS.
• Standardized, individualized, interactive and
  personalized
• self-help programs for smoking cessation. Health
  Psychol
• 199312399405.
• Shiffman S, Gitchell J, Strecher V. Real-world
  efficacy of
• computer-tailored smoking cessation material as a
  supplement
• to nicotine replacement. 10th Conference on
• Tobacco or Health, Beijing, August 1997.

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PDAs and Asthma

• A guideline implementation system using handheld
  computers for office management of asthma
  effects on adherence and patient
  outcomes.Shiffman RN, Freudigman M, Brandt CA,
  Liaw Y, Navedo DD.Department of Pediatrics,
  Yale School of Medicine, New Haven, CT
  06520-8009, USA. richard.shiffman_at_yale.eduOBJECT
  IVE To evaluate effects on the process and
  outcomes of care brought about by use of a
  handheld, computer-based system that implements
  the American Academy of Pediatrics guideline on
  office management of asthma exacerbations.
  DESIGN A before-after trial with randomly
  selected, office-based Connecticut pediatricians.
  In both the control and intervention phases,
  physicians collected data from 10 patient
  encounters for acute asthma exacerbations. During
  the intervention phase, the computer provided for
  structured encounter documentation and offered
  recommendations based on the guideline of the
  American Academy of Pediatrics. Patients were
  contacted by telephone 7 to 14 days after the
  visit to assess outcomes. RESULTS Nine
  study-physicians enrolled 91 patients in the
  control phase and 74 in the intervention phase.
  Follow-up information was available for 93 of
  encounters. Use of the intervention was
  associated with increased mean frequency/visit
  of 1) measurements of peak expiratory flow rate
  (2.18 vs 1.57) and oxygen saturation (1.12
  vs.42), and 2) administration of nebulized
  beta2-agonists (1.25 vs.71). Visits in the
  intervention phase lasted longer and fees were
  higher (145.61 vs 103.11). There were no
  significant differences in immediate disposition
  or subsequent emergency department visits,
  hospitalizations, missed school, or caretaker's
  missed work during the 7 days post visit.
  CONCLUSION Use of handheld computers that
  provide guideline-based decision support was
  associated with increased physician adherence to
  guideline recommendations however, visits were
  prolonged, fees were higher, and no improvement
  could be demonstrated with regard to the observed
  intermediate-term patient outcomes. Guideline
  implementers (and users) should be cautious about
  putting unvalidated recommendations into
  practice.

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More Evidence is on the way

• Robert Wood Johnson Prescription for Health
  initiative
• AHRQ PDA Tools Evaluation
• National Cancer Institute Evaluations
• Try it in your practice and collect data on
  outcomes

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Coming in November!More information at
Springer-Verlag Booth