Connected Health Technologies and Mobile Apps for Mental Health

Steven Chan, MD, MBAClinical Informatics FellowUniversity of California, San Francisco, School of MedicineSan Francisco, California

Co-investigatorUniversity of California, Davis, Psychiatry Virtual Collaborative Care NetworkSacramento, California

What is Telehealth?

American Telemedicine Association. www.americantelemed.org/main/about/about-telemedicine. Accessed May 30, 2017.

...Patient consultations via video conferencing, transmission of still images, e-health including patient portals, remote monitoring of vital signs, continuing medical education, consumer-focused wireless applications and nursing call centers are just some of the related applications.

“

Why Should I Care? DIGITAL NATIVES

• Parallel processing & multitasking

• Prefer graphics & visuals• Instant gratification &

rewards• Prefer to be networked• Learn with information

fast, presented in a random fashion

Your patients may be one of these:

Prensky M. On the Horizon. 2001;9(5)1-6. www.marcprensky.com/writing/Prensky%20-%20Digital%20Natives,%20Digital%20Immigrants%20-%20Part1.pdf. Accessed May 30, 2017.

DIGITAL IMMIGRANTS

• Use Internet for information second rather than first

• Print out email• Share computer content

in-person• Learn slowly, step-by-step,

one thing at a time

Patients Want Digital Tools

Torous J, et al. JMIR Mental Health. 2014;1(1):e5. Naslund JA, et al. J MentHealth. 2015;24(5):321-332.

Harvard

LSUNew Orleans

UC DavisSac County

U Wisconsin,Madison

Study of psychiatric outpatients shows 58% own smartphones (mirrors US general population).

71.4% psychiatric outpatients favor the idea of using smartphones for mental health.

Younger patients & private insurance (vs publicly‐insured) tend to own phones & favor app use.

Severe mental illness patients can use & accept telehealth interventions. (Efficacy not established yet.)

There are better ways to track health.

Frost JH, et al. J Med Internet Res. 2008;10(3):e15.

Diazepam

Bupropion

Escitalopram

Zolpidem

Celecoxib

Albuterol

Cefuroxime

Mometasone

Ezetimibe

Anxiety

Constipation

Depression

Emotional lability

Telehealth advantages

Diagram by @StevenChanMD. Advantages: Morland LA, et al. Current Opinion in Psychology. 2017;14:102-108.

Overcome barriers: location, transport, provider availability, limited open hours

Cost-effective in some cases

Opportunity to revamp operations & promote QI

VALUEreduced per-capita

costs

POPULATIONImproved

population health

QUALITYBetter satisfaction & care experience

An Economist’s Point of View

Powell AC, et al. Child Adolesc Psychiatr Clin N Am. 2017;26(1):125-133.

• Potential direct benefits include– Substitution for other forms of care– Prevention of higher-acuity illness– Higher rate of psychiatrist use– Increased competition of services driving lower

treatment costs– Lower operating costs for psychiatrists– Fewer missed appointments– Revenue for application developers

• Potential indirect benefits include improved physical health, enhanced current and future productivity, and reduced demands on caregivers

Discovering Apps

1. For communications & coordination.

2. To augment diagnosis, treatments.

3. As new intervention & monitoring.

See Patients on These Telehealth Platforms

Not a comprehensive list. Accurate as of January 3, 2017.

Name Service Hiring

Doctors on Demand Video visits Physicians, psychologists

American Well Telephone & video visits Physicians

1DocWay Psychiatry clinics, psychiatry hospitals, emergency psychiatry

Psychiatrists

MDLive Breakthrough Video talk therapy Licensed therapists

Talkspace Text messaging therapy LCSW, LMHC, LMFT, LPC, Psychologist, etc.

BetterHelp Text messaging therapy LCSW, LMFT, LPC, PsyD, or similar credentials

CloudVisit Private practive video Multiple providers

Practice Guidelines on ATA

American Telemedicine Association. http://thesource.americantelemed.org/resources/telemedicine-practice-guidelines.

Messaging Apps

Communications apps

DON’T use consumer email

DON’T use consumer social media

GO USE enterprise secure email where you’ve signed a HIPAA-compliant “business associates agreement” (BAA)

GO CHECK with your organization’s IT, legal, & risk teams

GO SET boundaries & rules with patients & care team members

You can go beyond mood charts

http://mood-trek.com/consumer/. Accessed May 30, 2017.

Apps can do much more than replace…

Journaling

Paper charts

Education handouts

Discovering Apps

1. For communications & coordination.

2. To augment diagnosis, treatments.

3. As new intervention & monitoring.

VA App Store — https://mobile.va.gov/

PTSD = posttraumatic stress disorder; TBI = traumatic brain injury. http://t2health.dcoe.mil/products/mobile-apps; https://mobile.va.gov/appstore. Accessed May 30, 2017.

ACT Coach, Breathe2Relax, CBT-I Coach, Concussion Coach, CPT Coach, Dream EZ, LifeArmor, Mindfulness Coach, Moving Forward, PE Coach, Positive Activity Jackpot, PTSD Coach, Stay Quit, T2 Mood Tracker, Tactical Breather, Virtual Hope Box

US Department of Defense National Center for Telehealth & Technology (T2) and US Department of Veterans Affairs

Insomnia, PTSD, TBI, nicotine addiction, depression, anxiety

VA App Store — https://mobile.va.gov/

KEY POINT

Many non-profits, government agencies, & established institutions are more trustworthy than amateur developers.

Virtual Hope Box

CI = confidence interval; VHB = Virtual Hope Box.Bush NE, et al. Psychiatr Serv. 2017;68(4):330-336.

VHB users (n = 58) reported significantly greater ability to cope with unpleasant emotions and thoughts (Coping Self-Efficacy Scale) at 3 (b = 2.41, 95% CI = .29–4.55) and 12 weeks (b = 2.99, 95% CI = .08–5.90) compared with the control group (printed materials about coping with suicidality, n = 60).

Stay Quit Coach

Hicks TAB, et al. J Dual Diagn. 2017;13(1):15-20.

Smokers with PTSD express interest in and helpfulness of Stay Quit Coach for remaining abstinent after a quit attempt. KEY POINT

Tools can be combined with programs, but “adequately powered clinical trials” are still in the works.

GAD-7 = Generalized Anxiety Disorder-7; PHQ-9 = Patient Health Questionnaire-9.Mohr DC, et al. J Med Internet Res. 2017;19(1):e10.

KEY POINT

Coach-assisted apps can significantly reduce depression & anxiety.

Intellicare

Of the 99 participants who initiated treatment, 90.1% (90/99) completed 8 weeks. Participants showed substantial reductions in the PHQ-9 and GAD-7 (P < .001).

Neither baseline PHQ-9 nor GAD-7 were significantly related to changes in depression or anxiety severity, or concurrent treatment with psychotherapy or pharmacotherapy.

https://intellicare.cbits.northwestern.edu. Accessed May 30, 2017.

KEY POINT

Good apps & platforms must work together, involving data sharing & data interoperability.

IntellicareThought Challenger, Daily Feats, Aspire, Purple Chill, Worry Knot, Slumber Time, iCope, My Mantra, Day to Day, Boost Me, MoveMe, Social Force

Northwestern University

Target depression & anxiety

http://sam-app.org.uk/. Accessed May 30, 2017.

KEY POINT

Interventions can be interactive and guided, making them more exciting than static paper instructions.

SAMUniversity of West of England

Targets depression, anxiety

www.anxietybc.com/resources/mindshift-app. Accessed May 30, 2017.

Quanbeck AR, et al. Implement Sci. 2014;29;9:65.Marsch LA, et al. J SubstAbuse Treat. 2015;59:30-37.

KEY POINT

Internet-delivered education can be as effective as those delivered by specialists (eg, HIV prevention, substance use).

MindShiftAnxiety Disorders Association of British Columbia & BC Children’s Hospital

NAMI = National Alliance on Mental Illness.www.nami.org/Find-Support/Air-App. Accessed May 30, 2017.

Naslund JA, et al. EpidemiolPsychiatr Sci. 2016;25(2):113-122.

NAMI AIR (“Anonymous Inspiring Relatable”)

Social network for individuals & caregivers

KEY POINT

Social networks can challenge stigma, increase consumer activation, and boost access to well-being interventions.

Discovering Apps

1. For communications & coordination.

2. To augment diagnosis, treatments.

3. As new intervention & monitoring.

https://en.wikipedia.org/wiki/Machine_learning. Accessed May 30, 2017.

field of study that gives computers the ability to learn without being explicitly programmed

“Alcohol Relapse Monitoring

Dulin PL, et al. Subst Abus. 2014;35(2):168-175.

KEY POINT

Interventions can be done in the heat of the moment (vs current practice of waiting for a clinic visit).

Chat Therapy

Courtesy @MichielRauws2, @X2_AI

KEY POINT

New disruptive services try to fill in service gaps (eg, remote, dangerous locations & during evening & late-night hours).

HIGH PRIORITY

Alert the psychiatrist. Message to top of queue.

NEGATIVE SENTIMENT

NORMAL PRIORITY

Place message in queue.

POSITIVE SENTIMENT

NLP Example of Sentiment Analysis

Example script and diagram by @StevenChanMD. Sentiment analysis in https://cloud.google.com/natural-language/.

PATIENT MESSAGES CARE

TEAM

MESSAGE SENT TO SENTIMENT ANALYSIS NATURAL LANGUAGE

PROCESSOR

COMPUTER DECIDES ON MESSAGE

PRIORITY

I think my depression and irritation is getting worse.

My sleep is great. The exercise plan you …

Affective Computing & Avatars

http://ict.usc.edu/prototypes/simsensei/. Accessed May 30, 2017.

MultiSense SimSensei

Duke University + Apple ResearchKit Face Emotion-Detection for Autism

https://autismandbeyond.researchkit.duke.edu; https://today.duke.edu/2015/10/autismbeyond. Accessed May 30, 2017.

Serious Games Research ADHD &

Autism

Courtesy @VahabzadehMD. Anguera JA, et al. Transl Psychiatry. 2016;6(9):e893.

ADHD & Autism

SPD = Sensory Processing Dysfunction.Anguera JA, et al. PLoS One. 2017;12(4):e0172616.

Following the cognitive intervention (4-week iPad video game), only the SPD children with inattention/hyperactivity showed both improvements in midline frontal theta activity and on a parental report of inattention.

33% of these individuals no longer met the clinical cut-off for inattention, with the parent-reported improvements persisting for 9 months.

Games Engage: Think Kids & Teens

Horne-Moyer HL, et al. Curr Psychiatry Rep. 2014;16(12):520.

KEY POINTS

Select games based on appeal to patients & meeting goals.

Co-play can help teach social skills, problem solving, with therapist feedback.

Educate on risks/benefits (eg, sexual/violent content, parental play with children).

Camera Sensors & Fitness Trackers

http://superheroworkoutgame.com/. Accessed May 30, 2017.

Naslund JA, et al. Psychiatry Res. 2016;244:139-144.

Naslund JA, et al. Ment Health Phys Act. 2016;10:10-17.

Macias C, et al. Psychiatr Q. 2015;86(4):505-519.

Kimhy D, et al. Psychiatr Serv. 2016;67(2):240-243.

KEY POINT

Fitness games and devicesare feasible to support weight loss in patients with serious mental illness.

Discovering Devices

Medisafe on Smartwatches

Chan S. www.imedicalapps.com/2015/03/review-medisafe-app-reminders/. March 23, 2015. Accessed May 30, 2017.

Specific Phobias

Social Anxiety

Alcohol Use

PTSD

Relaxation

Virtual Reality

Virtual Reality

US$900per unit

US$5per unit

Smartwatch & Wearables Data

Activity•Activity & exercise types

•Distance traveled•Movement while sleeping

•Light exposure

Physiological•Calories burned•Step count•Heart rate•Galvanic skin response

Diagram by @jnyfav. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.

Smartphone & Watch Sensors

GPS = global positioning satellite.Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.

Sensors Mainstream Apps Potential Clinical Uses

Accelerometers can

detect person’s

movement, number of

steps

Fitness tracking Exercise, weight loss,

activity level, movement

and gait detection

Location triangulated

through GPS, phone

cell tower, and WiFi

networks

Maps, driving directions,

location-specific

photography, social

media, augmented reality

games

Activity level, movement,

wandering behaviors,

peer support, addiction

trigger avoidance

Cameras to detect light,

the person’s face, and

the person’s

movements

Security, social media

and chat, exercise,

nutrition tracking,

augmented reality

Light exposure,

photographic self-

reflection and photo

journaling, peer support

1

2

3

Smartphone & Watch Sensors (cont’d)

Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.

Sensors Mainstream AppsPotential Clinical

Uses

Cameras with depth

perception and 3D

mapping

Augmented reality

games, indoor

mapping, 3D object

scanning

Exposure to stressful

environments or

objects with response

prevention

Compass Maps, driving

directions

Movement, wandering

behaviors

Humidity Weather Environmental comfort

indicator

4

5

6

Smartphone & Watch Sensors (cont’d)

Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.

Sensors Mainstream AppsPotential Clinical

UsesTemperature of

environment

Weather Environmental comfort

indicator

Microphone Telephone calls, audio

recording, social media

and chat, voice dictation

Activity level, speech

assessment, assess

ambient noise as

environmental comfort

indicator, voice dictation

for physical impairments

Screen taps with touch

pressure intensity

Games, Secondary

controls

Activity level, cognitive

exercises

7

8

9

Smartphone & Watch Sensors (cont’d)

Table by @StevenChanMD. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.More info in Glenn T, et al. Curr Psychiatry Rep.2014;16(12):523.

Sensors Mainstream AppsPotential Clinical

UsesHeart rate Fitness tracking Exercise, weight loss,

activity level,

biofeedback

Electrodermal activity

(skin conductance)

Stress testing Biofeedback

10

11

12

Developing Apps

Drag-and-Drop App Building

www.gocanvas.com. Accessed May 30, 2017.

Contract an External Developer

Have they previously worked with health systems?

Can they assure HIPAA and 42CFR compliance?

Can they assist with project management? How much do project changes cost?

Can they integrate w\ EHR?

…and will the company last?

Securing, Testing, & Implementing

Watch Out for Bogus Apps

Art by StockUnlimited. H/t @JohnTorousMD.Mani M, et al. JMIR Mhealth Uhealth. 2015;3(3):e82. Wilson H, et al. JMIR Mhealth Uhealth. 2016;4(3):e98. Larsen, ME, et al. PLoS One. 2016;11(4):e0152285.

700 mindfulness apps on the iTunes and Google Apps Marketplace—only 4% provided acceptable mindfulness training and education.58 apps claiming to offer sobriety assessments—“none... determined their efficacy in changing either drinking or driving behaviors.”Review of suicide apps found good safety plan apps, but none provided evidence-based support—some were even harmful (“listing lethal access to means or encouraging risky behaviour in a crisis”).

App Count

Search done April 5, 2016 for search terms in AppAnnie. Chan SR, et al. Healthcare. 2014;2(2):220-233.

Keyword Android iPhone

Depression 233 795

Anxiety 236 1185

Schizophrenia 224 32

Bipolar 245 172

Alcoholism 224 60

Perfectionism 0 0

App Count

Larsen ME, et al. JMIR Mhealth Uhealth. 2016;4(3):e96.

Volatile: “a clinically relevant app for depression [becomes] unavailable to download every 2.9 days.”

Apps Get Outdated Quickly

http://berkeleysciencereview.com/can-your-phone-cure-depression/. Accessed May 30, 2017.

Published in 2012

Half a decade ago!

None of the apps

cited are available

or updated for

years.

Industry is ahead of science & evaluation.It can take 10+ years to make new meds:

Image from www.phrma.org/sites/default/files/Drug%20Development%20Lifecycle.png.

3-6 y 6-7 y ½-2y

Consumer Apps Can’t Guarantee Privacy & Security

Huckvale K, et al. BMC Med. 2015;13:214.

×79

Consumer Apps Can’t Guarantee Privacy & Security

Huckvale K, et al. BMC Med. 2015;13:214.

Half of apps (50%, n = 35/70) included strong identifiers in transmitted information. Two-thirds of these (66%, n = 23/35, 29% of all apps) sent identifying information without encryption, including email addresses (n = 5), account login details (n = 5), full name (n = 2), or date of birth (n = 2).

KEY POINT

Inform & consent for apps, & discuss risks & benefits.

Can you text?

Image of Android Messages by https://play.google.com/store/apps/details?id=com.google.android.apps.messaging&hl=en.Drolet BC. JAMA. 2017 May 8;[Epub ahead of print].

“Texting to communicate health information is neither explicitly prohibited by HHS nor illegal in the United States.”“A combination of vigilant deidentification and maximizing available security features should maintain HIPAA compliance for text messaging.”“HIPAA compliance can...be maintained by deidentifying information before it is transmitted. Under the Safe Harbor Method, health information is no longer linked to an individual when 18 types of patient identifiers have been removed.”

2017 Federal Oversight

www.ftc.gov/tips-advice/business-center/guidance/mobile-health-apps-interactive-tool; www.fda.gov/MedicalDevices/DigitalHealth/MobileMedicalApplications/ucm255978.htm. Accessed May 30, 2017.

FTC — Federal Trade Commission

FDA — US Food & Drug Administration

Which laws apply to my health app?

www.ftc.gov/tips-advice/business-center/guidance/mobile-health-apps-interactive-tool. Accessed May 30, 2017.

Which Should You Use?

“enterprise software”nearly always a fee……because companies secure your data……and are HIPAA-compliant.

Try this test: Call them. Find their dedicated hotline for provider/practitioner support.

“consumer software”nearly always free……because the companies sell your data……despite claims of security.

Companies will reveal patient identities via the “friends you may know…” feature.

Epic, AthenaHealth, G Suite Gmail (paid)

Gmail (free), Facebook, LinkedIn, Twitter, SMS, MMS

In clinician’s office

Patient discusses symptoms

Clinician reviews history

Clinician recommends

treatment options

Patient decides on treatment

At home

Patient makes appointment with

clinic

Patient waits for appointment

Patient experiences

distress

App logs symptoms & records video

App provides initial triage &

screeningClinician

reviews app reports,

dashboard

App provides education

Using Apps in Clinical Workflows

Diagram by @jnyfav. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.

Sharing

Ease of Use

Efficacy

Privacy and Safety

Ground

PRIVACY & SAFETY: Privacy policy, Data collected, Protection/de-identification of data, Opt out of data collection, Delete data, Physical location of data, Security & encryption, HIPAA & CFR

GROUND level: Business model, Developer, Cost / In-App Purchases / Free, Advertising model, OS platform, Date last updated

EVIDENCE: Functionality vs Claimed functionality, Clinical studies & data evidence, feedback from users to support claims (app stores, review sites), and appearance of reasonable value

5

4

3

2

1

EASE OF USE: Easy to access, Customizable, Offline and limited Internet functionality, Platform availability, Accessibility for those with impaired vision or other disabilities

INTEROPERABILITY & DATA SHARING: Can it share data with electronic health records; can data be printed, exported, or downloaded; can share data with other user data tools (eg, through Apple HealthKit, Google Fit)

Ask yourself these questions about the app — from 1 to 5 — before “prescribing.”

Based on: American Psychiatric Association. App Evaluation Model. www.psychiatry.org/psychiatrists/practice/mental-health-apps/app-evaluation-model. Accessed May 30, 2017. Diagram by @jnyfav. Chan SR, et al. Data collection from non-patient interview sources. Telepsychiatry and Health Technologies – a guide for mental health professionals. Arlington, VA: American Psychiatric Association Publishing; 2017, In press.

Know How to Track & Block Permissions

https://play.google.com/store/apps/details?id=com.humberto.flashlight. Accessed May 30, 2017.

vs

Know How to Track & Block Permissions

Raggett D. July 2014. www.w3.org/2014/05/wp-trust-permissions/Overview.html. Accessed May 30, 2015.