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WE'RE TECHNICALLY A PLC, A PROFESSIONAL OR PRIVATE LIMITEO CORPORATION, ANO THE MORE I PROTOCOL-IZE THINGS, THE MORE PUSHBACKI GET. —JEFFREY WOO, M.O.

all rather subtle and complex, he notes, because a balance must be struck be- tween the ideal and the practical, with regard to how physicians really practice, and what kinds of policies they can real- istically adhere to.

TOWARDS THE FUTURE Looking towards the future, all those interviewed for this article agree: working out the mobility, security, and process issues in this whole area will

take years. Still, says Mike Carr, a Sara- sota, Fla.-based director at the Denver- based Aspen Advisors consulting firm, what's clear is that "The accountable care future is really going to require that clinicians and patients engage, in order to improve patients' health. The mobile devices that patients can use will be key to this, as well as con- nectivity with monitoring devices, but mobile computing will be a critical success factor in population health management," •

[ Part Two: Mobile Computing and Patient Population

The Promise of Mobile: Connecting to Underserved Populations

HOW ARE HEALTHCARE PROVIDERS, ADVOCACY GROUPS, VENDORS, AND OTHER STAKEHOLDERS ATTEMPT- ING TO ENGAGE PATIENTS IN UNDERSERVED POPULATIONS? CHECK YOUR PHONE

By Gabriel Perna

I f it hasn't arrived already, the era of mobile health (mHealth) is cer- tainly on the way.

Like a garden in the early days of spring, the market for mHealth apps, devices, and platforms is ripe with potential and possibilities. In many cases, patients are monitoring their health through smartphone apps and wearable health monitoring devices. In other instances, providers are using mobile technology to better connect with various populations of patients (see related story on page 8).

The possibilities seem limitless, and the market research backs the idea of this promise. The global market for mHealth is valued at $2 billion, ac- cording to research from the London- based research firm. Vision Gain, By 2017, the market will balloon to $27

billion, predicts Research2Guid- ance, another research firm. Other estimates, such as the one from Transparency Market Research, have their predictions set at a more mod- est $10,2 biUion by the year 2018.

For a growing number of health- care organizations, mHealth is being used to engage, serve, educate, and improve the health of socioeconomi- cally disadvantaged patients. Wheth- er it's simply by texting people tidbits of information or monitoring how much medication a patient is tak- ing, providers are finding meaningful ways to connect to the underserved.

NON-TRADITIONAL INTERVENTION The Center for Connected Health, a non-profit division of the Boston-

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based Partners Healthcare health sys- tem, is driving non-traditional medical interventions, in many cases specifi- cally aimed at changing behaviors in underserved populations. The way the Center for Connected Health's founder and director, Joseph C. Kvedar, M.D., ex- plains it, mobile is the perfect tool for changing behavior, because it's there when you need it.

"Mobile can be a gatherer of informa- tion, it can be a display tool for informa- tion, and it can be a messaging tool. It's even more dynamic in the underserved population because they have leap- frogged desktop technology and have essentially gone to mobile Internet as their primary source of engagement," Dr. Kvedar says.

The Center, until recently, has primar- ily connected with underserved popula- tions through text messaging. Kvedar says texting is a simpler, more ubiq- uitous form of communication than

smartphone applications, especially for underserved populations, so while the organization is in the process of build- ing an app for pain management, the method of engagement it employs is primarily text messaging.

The Center created text-messaging interventions for prenatal and addic- tion patients. Prenatal care, Kvedar says, provides an ideal opportunity for a text message intervention, because of the start and end date factor. Seventy- two percent of the women involved felt more connected with the obstetrics and gynecology (OB/GYN) doctor. The OB/ GYN practice also documented better show rates to appointments. The data was similarly positive for the addiction patients, who felt more connected to their practice.

TXT4HEALTH Similar to the Center's texting interven- tion programs is a nationwide initiative

piloted by three different Beacon com- munities called Txt4Health. The three communities. Crescent City (New Or- leans), Southeast Michigan, and Greater Cincinnati, all have populations with a high tendency for diabetes and thus were specific targets, reveals Mike Samet, public information officer of Hamilton County Public Health and the man who operated the Greater Cincin- nati's version of Txt4Health.

Within the course of a 14-week pro- gram. Greater Cincinnati Beacon re- layed targeted, detailed information on diabetes prevention to underserved communities. "It was a wide-open pro- gram in that anyone could participate, but we tried to concentrate on under- served communities because their pro- pensity for diabetes is higher," Samet ex- plains. "Also, that population often finds itself outside of traditional healthcare opportunities. Plus, because it was free, it seemed ideal for that group."

Mobile Health in Underserved Communities: An In-Depth Look

Wenalchee. Wash.. Leaders at Columbia Valley Community Health Center are educating monolingual Spanish speaking diabetics with an app that provides interactive resources such as videos and digital support groups

Cincinnati. Ohio: Greater Cincinnati Beacon was one of three Beacons that ran TxHHealth. a text-messaging intervention campaign aimed to educating underserved diabetics

Sacramento. Calif.: Dignity Health is using a bilinguat English-Spanish smartphone app to monitor asthma patients: the app caters the area's growing Hispanic population

Boston. Mass.: The Center for Connected Health, a non-profit division of Partners Healthcare, has connected witti underserved communities through text-messaging campaigns, focusing on prenatal and addiction patients

Columbia. Md.: The University of Maryland's Food Supplement Nutrition Education Program (FSNE) connected with lower-income families through a texting campaign, sending them general nutrition and fitness information and alerting them on local deals

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Participants fell into three buckets based on high, medium, and low risk factors. While the messages weren't on a personal level, there were specific pro- grams with a lot of positive reinforce- ments, follow-ups, and links to local resources. Greater Cincinnati Beacon sold the initiative as a "personal health coach in your pocket."

Both the Center for Connected Health and Greater Cincinnati Bea- con faced separate chal- lenges in their texting campaigns. At the Cen- ter, getting clinicians to adopt and buy in was a barrier, according to Kvedar, who said they didn't want to be held liable in case some- one texted them in the middle of the night. At Greater Cincinnati Beacon, it was about getting the word out. Along with various marketing campaigns, the organization reached out to local healthcare stake- holders.

"We worked literally a 'Who's Who' of the healthcare community in Cincinna- ti. That included some of the hospitals.

thanks to various environmental prob- lems. In addition, the city's burgeoning Latino population faces language bar- riers.

Dignity Health, a 42-hospital, multi- state health system, decided to team up with the California Healthcare Foundation and tackle this problem

by monitoring asthmatic patients on a daily basis through the use of a sen- sor on an inhaler and mo- bile app from startup app developer, Asthmapolis, Madison, Wis. Through it, physicians are able to de- termine how much medi- cation patients are using, when they're using it, and when they might be hav- ing an asthma attack.

For the region's Latino population, the app was

made available in Spanish as well, says Rich Roth, vice president of innovation at Dignity. More than being available in multiple languages though. Roth says it worked for them because it was simple.

"There are a lot of things out there that require you to do a lot of stuff, which you not might be able to do be-

WE WORKED LITERALLY A 'WHO'S WHO' OF THE HEALTHCARE COMMUNITY IN CINCINNATI. THAT INCLUDED SOME OF THE HOSPITALS, THE UNITED WAY, THE YMCA HAS A DEEP DIABETES INTERVEN- TION PROGRAM, AND WE WORKED WITH THE MEN- TAL HEALTH BOARD IN THE COUNTY. WE THREW THE DOORS OPEN. —MIKESAMET

the United Way, the YMCA has a deep diabetes intervention program, and we worked with the mental health board in the county. We threw the doors open," Samet says.

ASTHMA IN CALIFORNIA From area to area, the health challeng- es of underserved populations differ. While communities in the Midwest and South may have a higher propensity for diabetes, as Samet says, the folks in Sac- ramento, Calif, are dealing with asthma.

cause you are trying to live a normal life. You don't go online and do banking 50 hours a week. You do it on a transac- tional basis. That is the lesson for mo- bile health. With Asthmapolis, you use the inhaler as you normally would," says Roth. "The direction we're going to see over time is that if you make it simple, mobility has such tremendous opportu- nity to improve care."

In terms of connecting with a popula- tion that doesn't speak Enghsh, a com- parable solution was cooked up by the

Columbia Valley Community Health (CVCH). Dealing with a monolingual, Spanish-speaking patient population that primarily lives below the pov- erty line, CVCH's leaders invested in a smartphone app from WellFX, a Peta- luma, Calif.-based developer. The app provides diabetes patients with inter- active resources such as educational videos, digitized support groups where they can communicate with others that share the same disease, and text mes- sage-based reminders.

UNIQUE CHALLENGE AND OPPORTUNITY If there is a recurring lesson in the way providers are attempting to connect with underserved patients through mobile devices, it's essentially the question CVCH's medical director, Malcolm Butler, M.D., asked when he first came up with the idea that would lead to his organization's own inter- vention efforts.

"There's no way I can communicate everything that needs to be said on the management of diabetes in the course of 15 to 20 minutes a year. But what if every morning, while they're waiting for the bus, they get on their phone, go to [an app], and see a post from Dr. Butler on how their diabetes works?" Butler recalls asking before the app was cre- ated.

Fitting mHealth interventions into the everyday lives of patients is the unique opportunity and challenge in- herent in engaging underserved popu- lations. In the Txt4Health program, Hamilton County Public Health's Mike Samet says the organization had to fig- ure out the right amount of text mes- sages to send before it became a nui- sance for people. "One of the drawbacks to the program was that there was a high dropout rate," he notes.

As providers, advocacy groups, and other stakeholders look to empower socioeconomically disadvantaged pa- tients through the use of mHealth, while improving the quality of care in those areas, healthcare leaders are finding that they must first work to understand the population. Only then, they say, can they begin to change behaviors. •

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