Gede Pramana

iMHere: A Novel mHealth System for Supporting Self-Care in Management of Complex and Chronic Conditions

Background Individuals with chronic conditions are vulnerable to secondary complications that can be prevented with adherence to self-care routines. They benefit most from receiving effective treatments beyond acute care, usually in the form of regular follow-up and self-care support in their living environments. One such population is individuals with spina bifida (SB), the most common permanently disabling birth defect in the United States. A Wellness Program at the University of Pittsburgh in which wellness coordinators supervise the care of individuals with chronic disease has produced remarkably improved outcomes. However, time constraints and travel costs have limited its scale. Mobile telehealth service delivery is a potential solution for improving access to care for a larger population. Objective The project’s goal was to develop and implement a novel mHealth system to support complex self-care tasks, continuous adherence to regimens, monitoring of adherence, and secure two-way communications between patients and clinicians. Methods We developed and implemented a novel architecture of mHealth system called iMHere (iMobile Health and Rehabilitation) consisting of smartphone apps, a clinician portal, and a two-way communication protocol connecting the two. The process of implementing iMHere consisted of: (1) requirement analysis to identify clinically important functions that need to be supported, (2) design and development of the apps and the clinician portal, (3) development of efficient real-time bi-directional data exchange between the apps and the clinician portal, (4) usability studies on patients, and (5) implementation of the mHealth system in a clinical service delivery. Results There were 9 app features identified as relevant, and 5 apps were considered priority. There were 5 app features designed and developed to address the following issues: medication, skin care, bladder self-catheterization, bowel management, and mental health. The apps were designed to support a patient’s self-care tasks, send adherence data to the clinician portal, and receive personalized regimens from the portal. The Web-based portal was designed for clinicians to monitor patients’ conditions and to support self-care regimens. The two-way communication protocol was developed to facilitate secure and efficient data exchange between the apps and the portal. The 3 phases of usability study discovered usability issues in the areas of self-care workflow, navigation and interface, and communications between the apps and the portal. The system was used by 14 patients in the first 6 months of the clinical implementation, with 1 drop out due to having a poor wireless connection. The apps have been highly utilized consistently by patients, even those addressing complex issues such as medication and skincare. The patterns of utilization showed an increase in use in the first month, followed by a plateau. Conclusions The system was capable of supporting self-care and adherence to regimen, monitoring adherence, supporting clinician engagement with patients, and has been highly utilized.

Perspectives on the Evolution of Mobile (mHealth) Technologies and Application to Rehabilitation

Individuals with chronic conditions and disabilities who are vulnerable to secondary complications often require complex habilitative and rehabilitative services to prevent and treat these complications. This perspective article reviews the evolution of mHealth technologies and presents insights as to how this evolution informed our development of a novel mHealth system, iMHere (interactive mobile health and rehabilitation), and other technologies, including those used by the Veterans Administration. This article will explain the novel applications of mHealth for rehabilitation and specifically physical therapy. Perspectives on the roles of rehabilitation professionals in the delivery of health care using mHealth systems are included. Challenges to mHealth, including regulatory and funding issues, are discussed. This article also describes how mHealth can be used to improve patient satisfaction and delivery of care and to promote health and wellness.

VISYTER: Versatile and Integrated System for Telerehabilitation

The versatile and integrated system for telerehabilitation (VISYTER) is a software platform for developing various telerehabilitation applications. VISYTER has been designed to take into account the environments and requirements of rehabilitation services. The requirements considered in the platform design include minimal equipment beyond what is available in many rehabilitation settings, minimal maintenance, and ease of setup and operation. In addition, the platform has been designed to be able to adjust to different bandwidths, ranging from the very fast new generation of Internet to residential broadband connections. VISYTER is a secure integrated system that combines high-quality videoconferencing with access to electronic health records and other key tools in telerehabilitation such as stimuli presentation, remote multiple camera control, remote control of the display screen, and an eye contact teleprompter. The software platform is suitable for supporting low-volume services to homes, yet scalable to support high-volume enterprise-wide telehealth services. The VISYTER system has been used to develop a number of telerehabilitation applications, including a remote wheelchair prescription, adult autistic assessments, and international physical therapy teleconsultations. An evaluation of VISYTER for delivering a remote wheelchair prescription was conducted on 48 participants. Results of the evaluation indicate a high level of satisfaction from patients with the use of VISYTER. The versatility and cost-effectiveness of the platform has the potential for a wide range of telerehabilitation applications and potentially may lower the technical and economic barriers of telemedicine adoption.

Design Considerations for a Personalized Wheelchair Navigation System

Individuals with mobility impairments such as wheelchair users are often at a disadvantage when traveling to a new place, as their mobility can be easily affected by environmental barriers, and as such, even short trips can be difficult and perhaps impossible. We envision a personalized wheelchair navigation system based on a PDA equipped with wireless Internet access and GPS that can provide adaptive navigation support to wheelchair users in any geographic environment. Requirements, architectures and components of such a system are described in this paper.

Spatial and multidimensional visualization of Indonesia's village health statistics

BackgroundA community health assessment (CHA) is used to identify and address health issues in a given population. Effective CHA requires timely and comprehensive information from a wide variety of sources, such as: socio-economic data, disease surveillance, healthcare utilization, environmental data, and health resource allocation.Indonesia is a developing country with 235 million inhabitants over 13,000 islands. There are significant barriers to conducting CHA in developing countries like Indonesia, such as the high cost of computing resources and the lack of computing skills necessary to support such an assessment.At the University of Pittsburgh, we have developed the Spatial OLAP (On-Line Analytical Processing) Visualization and Analysis Tool (SOVAT) for performing CHA. SOVAT combines Geographic Information System (GIS) technology along with an advanced multidimensional data warehouse structure to facilitate analysis of large, disparate health, environmental, population, and spatial data.The objective of this paper is to demonstrate the potential of SOVAT for facilitating CHA among developing countries by using health, population, healthcare resources, and spatial data from Indonesia for use in two CHA cases studies.ResultsBureau of Statistics administered data sets from the Indonesian Census, and the Indonesian village statistics, were used in the case studies. The data consisted of: healthcare resources (number of healthcare professionals and facilities), population (census), morbidity and mortality, and spatial (GIS-formatted) information.The data was formatted, combined, and populated into SOVAT for CHA use. Case study 1 involves the distribution of healthcare professionals in Indonesia, while case study 2 involves malaria mortality. Screen shots are shown for both cases. The results for the CHA were retrieved in seconds and presented through the geospatial and numerical SOVAT interface.ConclusionThe case studies show the potential of spatial and multidimensional analysis using SOVAT for community health assessment in developing countries. Since SOVAT is based primarily on open-source components and can be deployed using small personal computers, it is cost-effective for developing countries. Also, combining the strength in analysis and the ease of use makes tools like SOVAT ideal for healthcare professionals without extensive computer skills.

Understanding intra-neighborhood patterns in PM2.5 and PM10 using mobile monitoring in Braddock, PA.

BackgroundBraddock, Pennsylvania is home to the Edgar Thomson Steel Works (ETSW), one of the few remaining active steel mills in the Pittsburgh region. An economically distressed area, Braddock exceeds average annual (>15 μg/m3) and daily (>35 μg/m3) National Ambient Air Quality Standards (NAAQS) for particulate matter (PM2.5).MethodsA mobile air monitoring study was designed and implemented in morning and afternoon hours in the summer and winter (2010–2011) to explore the within-neighborhood spatial and temporal (within-day and between-day) variability in PM2.5 and PM10.ResultsBoth pollutants displayed spatial variation between stops, and substantial temporal variation within and across study days. For summer morning sampling runs, site-specific mean PM2.5 ranged from 30.0 (SD = 3.3) to 55.1 (SD = 13.0) μg/m3. Mean PM10 ranged from 30.4 (SD = 2.5) to 69.7 (SD = 51.2) μg/m3, respectively. During summer months, afternoon concentrations were significantly lower than morning for both PM2.5 and PM10, potentially owing to morning subsidence inversions. Winter concentrations were lower than summer, on average, and showed lesser diurnal variation. Temperature, wind speed, and wind direction predicted significant variability in PM2.5 and PM10 in multiple linear regression models.ConclusionsData reveals significant morning versus afternoon variability and spatial variability in both PM2.5 and PM10 concentrations within Braddock. Information obtained on peak concentration periods, and the combined effects of industry, traffic, and elevation in this region informed the design of a larger stationary monitoring network.

Feasibility of Using Mobile Health to Promote Self-Management in Spina Bifida

ObjectiveTo determine feasibility of using the interactive Mobile Health and Rehabilitation (iMHere) system in spina bifida and its effects on psychosocial and medical outcomes. DesignIn a randomized controlled trial, 13 intervention participants using the iMHere system and receiving usual care and 10 control participants receiving usual care were followed for 1 year. ResultsFeasibility of use of the system was demonstrated by participants using a customized smartphone system for reminders to conduct various self-care tasks, upload photos of wounds, manage medications, complete mood surveys, and for secure messaging. High usage of the system was associated with positive changes in the subscales of the Adolescent Self-Management and Independence Scale II. ConclusionUse of the iMHere system in spina bifida is feasible and was associated with short-term self-reported improvements in self-management skill. This system holds promise for use in many diverse chronic care models to support and increase self-management skills.

Development of mHealth system for supporting self-management and remote consultation of skincare

BackgroundIndividuals with spina bifida (SB) are vulnerable to chronic skin complications such as wounds on the buttocks and lower extremities. Most of these complications can be prevented with adherence to self-care routines. We have developed a mobile health (mHealth) system for supporting self-care and management of skin problems called SkinCare as part of an mHealth suite called iMHere (interactive Mobile Health and Rehabilitation). The objective of this research is to develop an innovative mHealth system to support self-skincare tasks, skin condition monitoring, adherence to self-care regimens, skincare consultation, and secure two-way communications between patients and clinicians.MethodsIn order to support self-skincare tasks, the SkinCare app requires three main functions: (1) self-care task schedule and reminders, (2) skin condition monitoring and communications that include imaging, information about the skin problem, and consultation with clinician, and (3) secure two-way messaging between the patient and clinician (wellness coordinator). The SkinCare system we have developed consists of the SkinCare app, a clinician portal, and a two-way communication protocol connecting the two. The SkinCare system is one component of a more comprehensive system to support a wellness program for individuals with SB.ResultsThe SkinCare app has several features that include reminders to perform daily skin checks as well as the ability to report skin breakdown and injury, which uses a combination of skin images and descriptions. The SkinCare app provides reminders to visually inspect one’s skin as a preventative measure, often termed a “skin check.” The data is sent to the portal where clinicians can monitor patients’ conditions. Using the two-way communication, clinicians can receive pictures of the skin conditions, track progress in healing over time, and provide instructions for how to best care for the wound.ConclusionsThe system was capable of supporting self-care and adherence to regimen, monitoring adherence, and supporting clinician engagement with patients, as well as testing its feasibility in a long-term implementation. The study shows the feasibility of a long-term implementation of skincare mHealth systems to support self-care and two-way interactions between patients and clinicians.

Using Mobile Health Gamification to Facilitate Cognitive Behavioral Therapy Skills Practice in Child Anxiety Treatment: Open Clinical Trial

Background Cognitive behavioral therapy is an efficacious treatment for child anxiety disorders. Although efficacious, many children (40%-50%) do not show a significant reduction in symptoms or full recovery from primary anxiety diagnoses. One possibility is that they are unwilling to learn and practice cognitive behavioral therapy skills beyond therapy sessions. This can occur for a variety of reasons, including a lack of motivation, forgetfulness, and a lack of cognitive behavioral therapy skills understanding. Mobile health (mHealth) gamification provides a potential solution to improve cognitive behavioral therapy efficacy by delivering more engaging and interactive strategies to facilitate cognitive behavioral therapy skills practice in everyday lives (in vivo). Objective The goal of this project was to redesign an existing mHealth system called SmartCAT (Smartphone-enhanced Child Anxiety Treatment) so as to increase user engagement, retention, and learning facilitation by integrating gamification techniques and interactive features. Furthermore, this project assessed the effectiveness of gamification in improving user engagement and retention throughout posttreatment. Methods We redesigned and implemented the SmartCAT system consisting of a smartphone app for children and an integrated clinician portal. The gamified app contains (1) a series of interactive games and activities to reinforce skill understanding, (2) an in vivo skills coach that cues the participant to use cognitive behavioral therapy skills during real-world emotional experiences, (3) a home challenge module to encourage home-based exposure tasks, (4) a digital reward system that contains digital points and trophies, and (5) a therapist-patient messaging interface. Therapists used a secure Web-based portal connected to the app to set up required activities for each session, receive or send messages, manage participant rewards and challenges, and view data and figures summarizing the app usage. The system was implemented as an adjunctive component to brief cognitive behavioral therapy in an open clinical trial. To evaluate the effectiveness of gamification, we compared the app usage data at posttreatment with the earlier version of SmartCAT without gamification. Results Gamified SmartCAT was used frequently throughout treatment. On average, patients spent 35.59 min on the app (SD 64.18) completing 13.00 activities between each therapy session (SD 12.61). At the 0.10 significance level, the app usage of the gamified system (median 68.00) was higher than that of the earlier, nongamified SmartCAT version (median 37.00, U=76.00, P<.01). The amount of time spent on the gamified system (median 173.15) was significantly different from that of the earlier version (median 120.73, U=173.00, P=.06). Conclusions The gamified system showed good acceptability, usefulness, and engagement among anxious children receiving brief cognitive behavioral therapy treatment. Integrating an mHealth gamification platform within treatment for anxious children seems to increase involvement in shorter treatment. Further study is needed to evaluate increase in involvement in full-length treatment.

Accessibility of iMHere Smartphone Apps for Self-Care

Mobile health (mHealth) has been described as a patient-centered approach to health care. It aims to encourage self-care and self-monitoring for patients. The ability to perform real-time and systemic monitoring from mobile devices allows clinicians to assess medical and psychological symptoms and quickly deliver interventions in a patients natural environment. As the smartphone becomes ubiquitous, mHealth is a viable technology to empower patients to engage in preventive self-care.