Support for Self Management of Chronic Diseases through Mobile eHealthcare

1
Support for Self Management of Chronic Diseases
through Mobile eHealthcare

• Mihail Cocosila
• Ph.D. Candidate
• DeGroote School of Business, McMaster University
• March 14, 2006

2
Foreword

• In the 2005-2015 decade, deaths from chronic
  diseases will increase by 15 (and by 44 from
  diabetes alone) in Canada.
• Governments can wait no more and must take
  action.
• However, in the end, we really have to have a
  population thats aware and engaged in healthy
  living (former Federal Health Minister Ujjal
  Dosanjh)
• Can mobile IT help in this societal endeavour?

Leong, M. (2005) Lifestyle choices will kill a
million Canadians WHO. Over next 10 years.
National Post, October 5, 2005, p. A11
3
Agenda

• Introduction
• Self-management adherence
• Why mobile IT?
• M-healthcare motivators benefits
• M-healthcare demotivators obstacles
• Business aspects
• Conclusions and future research

4
Introduction

• Essential challenge in healthcare provision
  today (Cowling et al. 1999, Siau et al. 2002)

population demands for higher quality healthcare
limited resources of the system to meet the
demands
5
Introduction

• Demands aggravated by
• growing incidence of chronic diseases and
  conditions represent 54 of the burden of all
  illnesses worldwide in 2001 and over 65 in 2020
  (WHO 2003)
• ageing population (ratio working
  people/non-working pensioners in the developed
  world from 3/1 in 1999 to 1.5/1 in 2030)
  (PricewaterhouseCoopers 1999)
• todays, impatient patient
• better informed and educated, more dynamic,
  technically savvier
• expecting more effective and efficient care
• asking for more involvement in health decisions
  about their own illnesses
• willing to live a quasi-normal active life
  (Forker-Dunn 2003, Grimson and Grimson 2002,
  PricewaterhouseCoopers 1999, Rohm and Rohm 2002).

6
Introduction

• Healthcare system strained by
• limitation of resources shortage of hospital
  beds and healthcare personnel (Siau et al. 2002,
  Rohm and Rohm 2002)
• health providers always on the move and short of
  time (Cocosila and Archer, forthcoming).
• Possible responses to the challenge
• increasing focus on prevention, and patient
  pro-active attitude (Forker-Dunn 2003)
• encouraging patient self-management of some
  chronic illnesses in out-of-hospital (i.e.,
  outpatient) conditions (Maglaveras et al. 2002).

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Self-management adherence

• Chronic conditions and diseases are
• infectious (e.g., HIV-AIDS or tuberculosis), or
• non-communicable (e.g., diabetes, hypertension,
  or asthma).
• Several distinct features
• duration (permanent, or necessitate a long period
  of care)
• consequences (caused by non-reversible
  pathological deterioration leaving remnant
  disability) and,
• treatment (necessitate multidisciplinary
  management and special conditions and training
  for patient rehabilitation) (Cheah 2001 WHO
  2003).
• Serious concern for contemporary healthcare
• 10 of people aged over 75 years suffer from
  congestive heart failure (20 by the 2030)
  (Celler et al. 2001)
• asthma and depression are estimated to account
  for 5.1 billion and 12.4 billion, respectively,
  in annual direct medical costs in the U.S. alone
  (Weingarten et al. 2002).

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Self-management adherence

• Possible response delegate some patients
  responsibility for the management of their
  chronic illness at home.
• Patients would be able to live a life as normal
  and active as possible while
• taking medication (e.g., prescribed pills)
• performing self-tests (e.g., blood pressure,
  blood glucose)
• monitoring indicator levels (e.g., weight)
• following a certain diet (e.g., watching for food
  sugar)
• pursuing physical activity (e.g., practicing
  daily physical exercise)
• maintaining a healthy life-style in general
  (e.g., avoiding smoking or alcohol consumption).
• Intended gains
• reducing costs
• easing the work of healthcare providers
• improving patient quality of life and saving
  lives.

9
Self-management adherence

• Main barrier multifaceted and poorly understood
  patient non-adherence (approximately 50 of
  patient cases on average) (Bayliss et al. 2001,
  Dezii 2000, WHO 2003).
• Insufficient adherence has consequences for
• patients
• healthcare professionals
• government and society a veritable epidemic
  that causes 6 of hospital admissions (2 million
  a year in the U.S. alone) (Lowes 1998).
• AdherenceCompliance (Concordance) the extent
  to which a persons behaviour - taking
  medication, following a diet, and/or executing
  lifestyle changes, corresponds with agreed
  recommendations from a health care provider (WHO
  2003).

10
Self-management adherence
Adherence factors (Cocosila and Archer 2004, WHO
2003)
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Why mobile IT?

• Since increasing the effectiveness of adherence
  interventions may have a far greater impact on
  the health of the population than any improvement
  in specific medical treatments (Haynes et al.
  2001),
• but current methods of improving adherence for
  chronic health problems are complex,
  labor-intensive, and not predictably effective
  (McDonald et al. 2002),
• it is time that additional efforts be directed
  towards developing and testing innovative
  approaches to assist patients to follow treatment
  prescriptions (Haynes et al. 1996)
• An innovative approach mobile IT solutions.

12
Why mobile IT?...
Motivations and advantages of mobile IT
(Cocosila et al. 2004, Junglas and Watson 2003,
Mennecke and Strader 2003)
13
Why mobile IT?
Possible contributions from Mobile IT (Cocosila
and Archer 2005)
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Why mobile IT?

• Additional reasons
• mobile technology is already available and
  evolving fast exceptional development of mobile
  communications and data services in recent years
  (over 1 billion users worldwide)
• being mobile and connected has become a
  lifestyle trend across cultures
• mobile IT provides digital data (as needed for
  effective healthcare)
• the killer application of wireless text
  messaging or short messaging service (SMS)
  channel for cheap, asynchronous communications.

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Why mobile IT?

• A possible approach mobile health solutions
  embedded in wider adherence-improving
  initiatives.
• Using mobile IT to address outpatient
  non-adherence involves
• human and system issues
• business aspects.
• Major stakeholders in outpatient healthcare
  affected
• Patients
• Healthcare professionals
• Healthcare institutions
• Government and society.

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M-healthcare motivators benefits

• Patient motivators
• Medical reasons
• anytime-anywhere total mobility
• permanent contact with healthcare
• better quality of health services
• higher quality of a quasi-normal life
• predict and avoid serious health complications.
• Social reasons
• reduced absenteeism
• better social integration
• develop a responsive attitude, self-confidence,
  optimism, satisfaction, and improved education
• interested in and savvy about technology.

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M-healthcare motivators benefits

• Healthcare professional motivators and benefits
• Foster close and continuous dialogue with
  outpatients
• Improve outpatient active involvement in their
  own care
• Decrease waste of professional resources
• Shift professional workload from routine to
  quality interventions
• Ease work of home care providers
• Increase work satisfaction
• Reduce frequency of patient complaints.

18
M-healthcare motivators benefits

• Institution (health insurance and disease
  management companies) benefits
• Improve patient health behaviour
• Improve efficiency and effectiveness of
  outpatient care
• Save healthcare system time and money.

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M-healthcare motivators benefits

• Government and society benefits
• Reduce waste of resources
• Alleviate the contradiction between the
  increasing demand for better healthcare and
  societys limited resources
• Redistribute resources towards patients who need
  them most
• Allow better managing chronic illnesses on a
  regular basis
• Help people live a quasi-normal and active life,
  thus not being a burden for society
• Facilitate the modern tendency towards patient
  involvement in medical decisions.

20
M-healthcare demotivators obstacles

• Patient issues
• Intrinsic factors
• patient-related factors (psychological,
  attitudinal, and behavioural traits) not
  favourable to some adherence activities
• particular patient social situations.
• Difficulties with technology
• usability problems for elderly patients
• resistance to using cutting edge technologies and
  devices because of lower level of experience or
  familiarity
• attachment to older technologies
• lack of acceptance of complicated and un-robust
  devices and solutions.

21
M-healthcare demotivators obstacles

• Patient issues
• Interaction with devices
• dilemma about the optimal combination of patient
  and technology activity
• patients bothered by too much and too often
  interactions
• difficulty with limited input-output capabilities
  of mobile devices.
• Security and privacy
• reluctance to communicate personal data through
  wireless channels.

22
M-healthcare demotivators obstacles

• Healthcare professional uncertainties
• Outcome value
• uncertainty regarding accuracy and reliability of
  adherence measuring
• mistrust induced by the incorrect understanding
  of the type and time of expected results.
• Reimbursement
• no mechanism to reimburse most physicians for the
  time spent to interact remotely with patients or
  patient data.
• Overwork
• impossible to launch new healthcare initiatives
  that require more work
• danger of system overflow by patient-initiated
  synchronous communication demands
• risk of too many false alarms on patient status
  launched automatically by badly designed or tuned
  systems.

23
M-healthcare demotivators obstacles

• Healthcare professional uncertainties
• Work pattern changes
• physician concerns about being removed from their
  current central roles of healthcare provision
• physicians still bear the liability for patient
  care although they are not paid for the extra
  time allotted to homecare services
• physician refusal to use technology because of a
  belief that it degrades their professional
  status, or because of technophobia
• homecare nurses have to trade social relations
  for technology-mediated ones
• training required by new technology.

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M-healthcare demotivators obstacles

• Healthcare professional uncertainties
• Medical issues
• who bears the responsibility in case of
  misunderstandings due to temporary technology
  failures?
• who would be legally responsible for third party
  advice from social groups facilitated by the
  technology?
• patient data being made available to third
  parties in discussion groups.
• Security and privacy
• uncertainty about best data storage approach
  distributed or centralized
• insufficient privacy when patients communicate
  from public locations with healthcare
  professionals.

25
M-healthcare demotivators obstacles

• Institution (health insurance and disease
  management companies) issues
• Technology choice and implementation concerns
• High investment costs
• Contradiction between standardized practices and
  patient centeredness
• Economies of scale and reaching a critical number
  of users.

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M-healthcare demotivators obstacles

• Healthcare system concerns
• Technology obstacles
• need to use an open platform to facilitate
  collaboration with existing or future systems
• need to use a highly customizable technology
• need to address technology problems early in the
  design.
• Human barriers
• alteration of existing homecare systems
• create, change, or cut jobs
• train people for support centres empowered by
  wireless capabilities
• face significant stakeholder resistance to
  change.

27
Business aspects
28
Business aspects

• Financial costs of non-adherence
• Intrinsic costs - the actual waste of not taking
  a medication or not attending a
  consultation/prescribed test
• e.g., overall cost of missed appointments in
  England alone amounts to approx. 716 million
  U.S. per year
• paradoxical situation sometimes increased
  adherence does not lower the medical costs (e.g.,
  expected reduction in hospitalization is offset
  by increases in drug expenses).
• Illness-related costs - medical (i.e., direct)
  and social (i.e., indirect) costs of chronic
  illnesses triggered and/or aggravated by poor
  adherence
• represent a pure waste.

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Business aspects

• Savings generated by adherence
• Direct savings - decrease of costs for medical
  services (e.g., hospitalization, visits at the
  primary care centre, ambulatory care) and
  medication
• e.g., 14-46 of the on-site nursing activities in
  the U.K. and U.S.A. could be replaced by
  telecare, with net savings of approx. 2.25
  million U.S. per annum for a typical U.K. area
  health community and 60-85 per patient per
  activity in the U.S.A.
• Indirect savings - reduction in personal and
  social costs generated by the chronic illness
  (e.g., absenteeism, early retirement, or
  premature death)
• e.g., a German study demonstrated approx. 800.7
  U.S. per year per patient savings from the
  telecare of 46 diabetics because of reductions in
  travel time and missed work.

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Business aspects

• Cost of implementing m-healthcare adherence
  initiatives
• Investment costs
• Technology spending - central infrastructure
  (e.g., servers, computers, software, office
  spaces) and mobile outpatient devices
• Human resources costs - personnel training,
  hiring, or re-assigning to other tasks.
• Operating costs
• Factors of operating cost reduction
• Highly automation of interventions based on
  patient segmentation and prioritizing
• Large outpatient mass
• Patients partial support.

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Conclusions and future research

• Mobile solutions may help all major stakeholders
  in addressing outpatient non-adherence.
• Most actors would face behavioural,
  organizational, technological, and financial
  adoption barriers of various intensity.
• Future research should investigate implications
  for accommodating m-healthcare solutions
• changes necessary to existing outpatient care
  systems
• specific business cases.

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Messages to remember

• M-Healthcare for non-adherence could not
• help patients who are being non-adherent for
  psychological and attitudinal reasons
• replace the patient-health provider dialogue
• be justified by its novelty but by improvements
  in the quality and cost effectiveness of health
  care processes
• solve by itself existing organizational and
  managerial problems in the healthcare processes
  (Archer 2004, Cocosila and Archer 2004).
• M-Healthcare for non-adherence could
• support multi-dimensional adherence clinical
  initiatives (Cocosila and Archer 2004)
• add value to remote care while addressing several
  adherence key factors (Davies and Henderson
  2003).
• An important motivator to remember enhancing
  patient adherence appears to be more effective
  than the medical treatment itself (Haynes et al.
  2005).

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Thank you!

• Contact
• Mihail Cocosila
• Ph.D. Candidate
• DeGroote School of Business,
• McMaster University, Hamilton, Canada
• cocosim_at_mcmaster.ca