By Janice Petrella Lynch, MSN, RN
Mobile health technology has broadened nurses’ horizons beyond what anyone could have imagined, giving them the ability to improve care and communication and educate patients in managing their own health. No longer do nurses need to assess and make clinical decisions based only on office visits, episodic emergency care and hospitalizations. By using technologies from smartphones to wearable activity trackers and Web-based or downloadable apps, they can monitor patients in the home setting.
Healthcare professionals and organizations have only begun to scratch the surface of this avenue in caring for and educating patients, families and communities. With the support of their interprofessional colleagues, nurses have created and developed mHealth tools, improving patient care and empowering patients and families in the process.
For the past 10 years, Rebecca Schnall, PhD, RN, assistant professor of nursing, Columbia University School of Nursing, N.Y., has focused her work and research on using informatics strategies for improving the lives of people from underserved communities. The informatics tools she has developed are all about “giving patients information to empower themselves so they can more easily interact with providers and make decisions about their own health and healthcare,” Schnall said.
Her work has targeted individuals living with and at risk for HIV. She recently was awarded two grants from the National Institutes of Health and the Agency for Healthcare Research and Quality to conduct research focused on using mHealth technology to help people with HIV manage their symptoms.
The AHRQ-funded project will use avatars on a mobile platform and deliver self-care strategies to these individuals, Schnall said. This work is based on the previous paper-based tool developed by William Holzemer, PhD, RN, FAAN, dean and distinguished professor at the School of Nursing, Rutgers, The State University of New Jersey, while he was at the UCSF School of Nursing.
Similarly, the NIH-funded project seeks to help patients with HIV and comorbid conditions manage their symptoms using a mobile tool. Via a national survey, this project will identify the symptoms these individuals experience.
Maximizing the tool
Schnall sees other benefits to apps that support patients with symptom management strategies. “HIV is a chronic condition, and the findings from this work can reasonably be transferable to other chronic conditions,” she said. “Given the proliferation and growth of chronic diseases like diabetes and heart disease and our aging population with comorbid conditions, [mHealth] work is timely and of great import for helping improve the lives of persons living with chronic diseases.”
Anne Teitelman, PhD, RN, FNP-BC, FAANP, FAAN, also knows about maximizing the capabilities of an mHealth tool and enabling patients and consumers in managing their care. Recognizing the need to augment patient education outside of the office setting, Teitelman, who is the Patricia Bleznak Silverstein and Howard A. Silverstein Endowed Term Chair in Global Women’s Health, associate professor of nursing, University of Pennsylvania School of Nursing, Philadelphia, created a computerized preassessment tool focused on patients’ barriers to preventing cervical cancer. Once patients complete the profile and preassessment tool in the provider’s waiting room, a nursing student, who serves as a research assistant, provides tailored information, based on the patients’ responses.
Both the preassessment tool and the one-on-one informational sessions focus on adherence to receiving the three doses of the HPV vaccine, using condoms and having regular PAP smears, as well as the need for smoking cessation. “Cervical cancer is higher in minorities and low-income groups, and we also know that these particular groups need to be supported in completing the HPV vaccines,” Teitelman said. “We’re targeting the 18-26 age group with our project since that group is lagging behind in receiving the HPV vaccines.”
Teitelman and colleagues didn’t stop there. She received funding to create the free downloadable app called Now I Know, which evolved from another prototype app, Everhealthier Women, described as an app “that could save your life” by O magazine.
In the Now I Know app, the consumer will receive notifications offering two theory-based, educational stories every week for six months on HPV vaccine completion and other cervical cancer prevention strategies, as well as links to other information and resources. It also includes a discussion board and feedback from other users and experts in the field. Users can receive test results and be reminded of when they are due for their next vaccine.
From concept to reality
It was Nancy P. Hanrahan’s foresight and passion that led to the creation of University of Pennsylvania’s Nursing’s Health Technology Lab where she developed and coordinated the Health Tech incubator program. Working with undergraduate and graduate students from all disciplines, she helped them find appropriate technology and marketing components for new ideas, innovations, pathways and products. “The students actually began start-up companies, and we partnered with business students and faculty and corporate businesses that offered their expertise in marketing and testing of the innovations in the marketplace,” she said.
One nursing student played a key role in the development of a mental health app designed specifically for college students, while another nursing student designed the gaming methods used for the app, said Hanrahan.
Hanrahan, PhD, RN, FAAN, is now dean and professor for the School of Nursing and associate dean of Bouve College of Health Sciences, Northeastern University, Boston. In her new role at Northeastern she and the school will work closely with other schools within BCHS on mHealth projects. “An integrated, interdisciplinary approach is essential in education and technological innovation, and our moving away from silos will only enhance our learning, our thinking and our creativity,” she said.
A strong proponent of technological advances in mHealth, she believes mHealth will improve patient advocacy and healthcare delivery and increase efficiency of care. “Nurses are advocates and experts in patient care and the patient experience. In this powerful dual role they can be leaders in technological innovation — and now is the time to get involved,” she said.
Hanrahan speaks from experience. Funded by the American Nurses Foundation, Hanrahan created a Web-based PTSD nurse toolkit in 2014 that teaches nurses about the condition and uses a gaming component to reinforce learning. It is now being developed in app form. Hanrahan plans on adding a list of provider support resources for patients. “Nurses work with veterans and their families in every possible setting, and they need to be able to determine at what level of suffering they are and reinforce help-seeking behaviors with them,” said Hanrahan. “With support from the toolkit, nurses can be facilitators to help PTSD sufferers receive care.”
Hanrahan credits the interprofessional team who worked together to develop the program, “enabling others to deliver the best possible care and overcome care barriers in the process.”
Targeting patient needs
Nurse experts agree mHealth technology has the potential to transform healthcare delivery. It’s also clear that mHealth tools need to be tailored to meet specific patient needs, said Ryan J. Shaw, PhD, RN, assistant professor, School of Nursing, Center for Health Informatics, Center for Precision Medicine, Duke University School of Nursing, Durham, N.C.
Shaw is part of a team that includes a programmer, physician and health scientist, who are developing an app that measures walking and balancing abilities of the elderly. The ultimate goal is to use the data collected to predict those at high risk for falls and provide preventive interventions to them. “These data have huge implications for our elderly and us, and [the app] is an easy-to-use tool that can be used as an objective assessment in our communities and in retirement communities,” he said.
Along with colleagues, Terri H. Lipman, PhD, RN, CRNP, FAAN, created a Web-based text/short messaging system targeted specifically for youth with newly diagnosed type 1 diabetes. Lipman is an assistant dean for community engagement, Miriam Stirl endowed term professor of nutrition and professor of nursing of children, University of Pennsylvania School of Nursing, Philadelphia, and nurse practitioner at Children’s Hospital of Philadelphia.
Designed for patients age 10-17, MyDiaText provides text message reminders that help participants work toward a healthy diabetes lifestyle and improve self-management practices. “Using the American Diabetes Association guidelines, we collaborate with our patients to select particular health goals,” Lipman said. “For example, if the goal is to eat more fruits and vegetables, daily text messages provide a reminder, a link to an appropriate site on the topic or a game to play reinforcing knowledge.”
After creating a profile on MyDiaText.com, participants earn points toward their goal as they rate their progress and take quizzes. As an incentive, points earn printable certificates.
The short messaging system is a collaborative initiative among the School of Nursing, the College of Engineering and Applied Sciences at UPenn and the Diabetes Center for Children at CHOP. Initially created as part of a University of Pennsylvania Year of the Games challenge in 2012, the SMS won first prize in the school of nursing’s Game of Solutions for Healthcare.
Lipman and her colleagues have determined the feasibility and functionality of individuals receiving SMS educational and motivational messages. “It’s been quite a learning experience, right from its inception,” Lipman said. “While engineers had the expertise in technology development, nurses were invaluable in their input related to diabetes management, national diabetes guidelines, issues affecting youth and adolescents and reasonable expectations of providers. The nurses also were adamant the design could not move forward without the input of youth with diabetes and their families. This program, like other mHealth tools, provides a unique approach to interact with patients in a manner that is familiar and age-appropriate. Our learners can access information at their convenience, and they collaborate with us in identifying their health needs and priorities.”
Challenges, opportunities ahead
There are more than 100,000 health apps available in iTunes and the GooglePlay store (http://research2guidance.com/), and nurses are well aware of the volume of mHealth technology. “Given the robustness of the current marketplace, it can be overwhelming for providers to find ones appropriate for their patients,” Schnall said.
In his work, Shaw also has found that mHealth tools may result in data overload for those providers who are tracking the information. “When we look to the future, our patients are and will continue to be monitored, on much larger scales, between office visits, and we will need to be comfortable at looking at a lot of data,” he said, adding that tracking patients day to day results in better clinical decisions.
As reimbursement models shift more and more to pay for performance, we will need to assume, as nurses, the role of data managers, he said. “In addition, much of the data gathered from mHealth tools now are able to come back to the EHR, which is a definite advantage to all of us,” Shaw added.
Shaw created a Web-based mobile health platform, which has enabled him and his colleagues to gather patient data from a variety of devices and sensors into a secure database.
Recruiting three healthy and three chronically ill participants who provided data on 11 health indicators through a Fitbit accelerometer, wireless blood pressure cuff, wireless scale, wireless pulse oximeter and a diet app, he and his colleagues discovered that “sicker and more chronically ill patients, who could benefit from our mHealth devices, are actually the ones who often don’t use them,” Shaw said. “Results also indicate that device fatigue may be a significant problem.”
Nurse experts agree it’s important for nurses to get involved in the development of mHealth tools that support patients as well as themselves in their clinical practice. “As nurses, we identify the day-to-day needs and healthcare challenges of our patients,” Teitelman said. “When we partner with our interprofessional colleagues, it can result in fruitful collaborations, creative solutions and partners who can support us with technological solutions. Our ideas become realities.”
Janice Petrella Lynch, MSN, RN, is nurse editor/nurse executive.
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