Challenges to Identifying Potential Participants Using a New EMR

By Stephen Rothemich, MD, MS, BreathEasy Co-Principal Investigator and Clinical Lead

With BreathEasy’s focus on people with asthma and comorbid anxiety and/or depression, one of the challenges is how to identify potential subjects for upcoming focus groups. While we are working with two inner-city clinics using the same electronic medical record (EMR), the process has not been as simple as you might expect, as our health system is still in the process of implementing the EMR.

Ideally we could have used patients’ problem lists in the EMR to identify those with the overlapping conditions of interest. While both practices have been using the EMR for labs and prescriptions for a while now, one site began full electronic documentation just a few months ago. Since it will take a while for these practice populations to have office visits, most patients don’t yet have an electronic problem list. Identifying potential subjects starting with manual reviews of the lists in paper charts was impractical; there were 6,277 patients in our target age range!

Next was the diagnosis billing codes from recent visits. Here we encountered two pitfalls: 1) every chronic condition present or even addressed at a visit doesn’t necessarily get included in the maximum of four diagnosis codes that we submit for each visit and 2) our billing system is separate from our EMR system. Since we just had access to the latter for this project, we could only capture billing diagnoses associated with orders for labs or x-rays.

That left the medication lists. Both clinics have been using the EMR to generate prescriptions for over a year. So while we incorporated data from problem and diagnosis lists, our search strategy relied on the better populated medication lists. However, medications can be prescribed for more than one purpose. Some antidepressants are also used for sleep or chronic pain, or even conditions we needed to exclude, such as bipolar disorder. An oral medication might be used for allergies and not for asthma control.

We found 271 potential subjects based on all available electronic data in the problem lists, diagnoses, and medications that might be used for the target conditions. Because we relied so heavily on medication data and the exact indication for many prescriptions was ambiguous, review of electronic charts was necessary in 176 cases. Paper charts were reviewed for 38 patients where EMR review was not helpful. All in all, we had 151 subjects with the conditions of interest. While we didn’t have to do the whole process with paper chart review, good electronic problem lists would have made life easier. So I’ve decided to stop grumbling about building those lists when I see my own patients. Stay tuned to learn what we’ve heard from the focus groups!

Scanning the marketplace for asthma, anxiety and depression tracking applications

By Rita Sembajwe, Health Informatics Specialist, BreathEasy Project Manager, RTI International.

Read all of the BreathEasy blog posts.

As the BreathEasy project moves along, the time has come for the team to synthesize our mobile phone application findings related to asthma, anxiety and depression in order to compare them against each other and determine a baseline. Doing this allows us to improve or advance the baseline, instead of duplicating what already exists.

Both the Android and iPhone marketplaces already host some progressive applications. We are reviewing a handful of them and in the process acknowledging things like: user ratings; differences and similarities in technical and scientific features; user friendly architecture; and their target audience.

The asthma applications range from: applications that track peaklfow readings with the help of a graph; electronic asthma journals that track an individual’s asthma symptoms and medication; and applications that do a combination of both. A majority of the depression applications use a set of questions or a depression scale, e.g. HDRS17, built-in to detect and track depression symptoms.  All of the anxiety tracking applications in our selection were a combination of depression, or asthma tracking applications. 

In their own way, all the applications promote innovate ways to track and control conditions, but so far the Asthma Journal is our favorite when it comes to choosing an application that inspires the BreathEasy application development process. It tracks an individual’s asthma symptoms and medication, and has the ability to automatically share them with clinicians and whoever else via Google Health. A similar application on iPhone, Asthma MD, also tracks and charts asthma symptoms and enables the transfer of data to clinicians.

It is also worth highlighting the asthma and anxiety application, TBDeluxe, developed by Kumquat Portable Apps on Android.  It trains those who need to correct their breathing volume on how to breathe.  It tracks an individual’s breathing and guides inhalation and exhalation allowing the oxygenation of organs and systems and in turn reducing symptoms of allergies, asthma, anxiety, stress, and panic attacks, among others. 

BreathEasy will expand on the baseline of the marketplace by developing an Android based, user friendly application that tracks patient’s symptoms of asthma, anxiety and depression, by capturing relevant observations of daily living (ODLs).  Data collected will then be directly available to clinicians via a web dashboard. The target population of this application will be involved in the design and development of this project, through requirements gathering and testing.  We think our user centered design approach will spell success. To hear more about this application…stay tuned!

The Clock is Ticking

By Amireh Ghorob, iN Touch Program Manager, San Francisco General Hospital.

Read all iN Touch blog posts.

Imagine Maria, a 19 year-old patient, on the exam table at a routine 15-minute physician visit. Maria has been recently diagnosed with diabetes and is struggling with her weight. Her last two blood pressure readings were high. She is worried that she may have a sexually transmitted disease because she just discovered her boyfriend has been cheating on her and has been feeling very down lately. Assuming she was able to express all these concerns, her primary care physician must decide which issues to tackle now and which must wait until the next visit. In today’s health climate, it is impossible for the 15-minute visit to address acute, chronic, and preventive care, build meaningful relationships with patients, and manage multiple diagnoses. 

Put Me in Coach!
Enter the “health coach”: a member of the health care team other than a physician, nurse-practitioner, or physician’s assistant. At the Family Health Center in San Francisco, health coaching was launched in 2006. In 2008, the Teen and Young Adult Clinic at the Family Health Center implemented Takin’ Charge, matching health coaches with 16-25 year old patients at risk for cardiovascular diseases. 

Health coaches work to help patients become active creators of their care plans. They are trained to provide self-management support, health education, assistance with behavior change and medication adherence, and between-visit care. They interact with patients in the clinic (before, during and after a visit)  and have demonstrated that members of the health care team can successfully engage patients by using phone calls, texting, email, and in-person coaching sessions between-visits.

Game Time
A person spends a very small part of their life being a “patient.” Consequently, the health care team gets only a glimpse of people’s lives. Health coaching expands the 15-minute visit and engages the patient more. But coaches face the same challenges as the rest of the health care team:  difficulty getting in touch with patient, gaining the trust of patients, and missed appointments. Collecting ODLs will give the coach more insight about the person who is their patient.  But how will collection of ODLs impact patients? Will it increase patient engagement, foster more trust and improve adherence? 

Ready. Set. Go.
Health coaches rely on patient recall when assisting with behavior change action plans during their weekly or biweekly interactions. By asking patients to upload ODLs pertaining to exercise habits, dietary choices and stress, we want to capture real-time lifestyle choices and the patient’s experiences as they occur.  We hope this will portray a more accurate picture of the patient’s life as they are living it. Will this help patients and health coaches collaborate in the creation of manageable and successful action plans? What other advantages may occur?  And are there disadvantages we can anticipate and plan for?    

Taking the time to focus

By Barbara L. Massoudi, RTI International, BreathEasy Principal Investigator.

The BreathEasy team has spent significant time this past month developing our focus group guides to begin to understand the users’ (both patients’ and clinicians’) needs for the PHR tool.  The guides will help us facilitate the discussion around particular topics that are of interest to our research team. There are so many things we’d like to know about the users’ needs, preferences, opinions, beliefs, etc., that paring down the topics is challenging. Here’s are some of the questions we’re thinking about including, please let me know in the comments if you have some other ideas we’d want to consider as well.

Living with asthma and depression or anxiety
What are the biggest challenges in living with these diseases or conditions? How do they affect your daily life? Does one condition seem to outweigh the other? Do these conditions make the other worse?

How easy or difficult is it to talk with your doctor or nurse about your symptoms? Do you keep notes about your health condition or do you just try to remember? How long is it usually between visits to the doctor? Do you find that you have trouble answering questions when it’s been a long time between visits?

How would you feel about a personal health record tool to help you with your conditions? What should it be able to do? How would you use it? What do you think it would be important for your doctor to know about your symptoms and health behaviors, including your personal triggers (read ODLs)? Do you think it would be easy or difficult to keep track of these things?

The BreathEasy smart phone app
Do you use a cell phone? Is your cell phone a smart phone? Do you use apps? What do you like about your favorite apps? Does your phone have a virtual keyboard? Do you find it easy to use or would you prefer to use a physical keyboard?

What would you think about using a free smart phone app to collect and record your symptoms and health behaviors? What problems could you see with using a smart phone app this way? Would you report symptoms as they occurred, or at the end of the day?

Communicating with the doctors and nurses

How would you feel about your healthcare providers being able to see what you record between appointments? How would you feel about discussing the symptoms and health behaviors you recorded with your healthcare provider?  How do you think they would react to this type of system?

What’s next?
Once we hold the focus groups and gather the users’ inputs, we’ll being developing the BreathEasy tool. A subset of our focus group participants will then return in the fall to evaluate the prototype through some usability testing. More on that to come…

A Balancing Act - Tackling Teen Obesity and Depression

By Katherine Kim, San Francisco State University, iN Touch Principal Investigator.

Our project is in full swing and that means we are increasingly clear about the promise that lies ahead if we are successful. As often happens, the more we talk about the project, the more we find others working on similar issues.

Last week, I met Professor Karl-Walter Kohlmann, a German health psychologist who was visiting San Francisco State.  He kindly sent me two recent papers from his research group. The first paper highlighted the high rates of anxiety and depression among children and teens who are overweight or obese. The other paper showed a difference in negative coping strategies (overeating, social isolation, computer and television use, etc.) used by children who saw themselves as overweight/obese vs. those who saw themselves as not (even if their BMI was in the overweight/obese range). It heightened my awareness of how thoughtfully and carefully we must interact with youth in our project so as not to perpetuate the problem by over-identifying them with a clinical label.  We want to protect their identity and esteem while we help them realistically change their health behavior. 

The paper recommended that treatment components for youth include nutrition, physical activity and behavioral skills (e.g. stress management, self-regulation and evaluation skills, and social support). I think we are on the right track with iN Touch by helping the patient manage activities related to all three components. I do have a question though. Might the use of the iPhone/iPod Touch increase the positive social integration of our population of teens by giving them another means of communication and another supportive person to engage with, the health coach?  Or, will the device end up like the TV and computer, an enabler of sedentariness and isolation. 

I’d love to hear what you think.

FitBaby - Making Record-Keeping Easy for Parents of Premature Infants

This post is the fourth in a series that will introduce you to our five new grantee teams.

By Karen Cheng, Charles Drew University, FitBaby Principal Investigator

Four years ago, Micah, the son of one of my best friends was born with a condition that kept him in the Neonatal Intensive Care Unit (NICU) for nearly 30 days. My heart bled as I stood with my friend in the NICU – her joy of having a newborn shattered by the pain of seeing her son in an incubator.

For the next year, after Micah went home, I watched my friend and her husband plug away, day after day, in their care for Micah. They carefully recorded on paper charts how much he ate, whether he threw up, whether he pooped, how long he slept, when he took his meds. And, it was only years later that my friend could identify her fluctuating emotions at the time – shock, sadness, anger, fleeting moments of acceptance – as signs of post-partum depression.

Our project, FitBaby, is designed to make those first few months out of the NICU a little easier for parents and other caregivers of premature infants.  Approximately one out of every eight babies in the US is born prematurely and many of these infants will face long-term health problems. In addition, nearly 40% of mothers of premature babies suffer post-partum depression at some point in the first year after delivery.

The FitBaby Project
FitBaby allows parents to use mobile phones to quickly and easily enter information, such as a baby’s sleeping and feeding patterns. The FitBaby system will also include sensors, placed strategically around the home, that can automatically record information such as how much the baby is moving or how much the baby weighs – without extra work on the part of parents. FitBaby can help keep many of the daily records, and parents can focus on resting and enjoying their babies. Parents, as well as pediatricians, can view summaries of the information gathered by FitBaby to enable them to identify the early signs of illness.

We are also exploring the recording of parents’ emotional well-being so that they can better understood their own emotional health and maybe even identify the early signs of post-partum depression. 

The FitBaby Team
This project is a collaborative effort among University of California, Irvine; Charles Drew University of Medicine and Science; and University of California, Irvine Medical Center. Our diverse team is working closely together to design and test the FitBaby system. As Co-PI’s Gillian Hayes and I provide overall direction for the project. Monica Tentori, Sen Hirano, Sun Young Park, and Leslie Liu are designing and developing FitBaby. And our clinical partners, Dan Cooper, Julia Rich, and Sheba George, are working with us to ensure that FitBaby assists pediatricians and improves the doctor-patient relationship.

We are very excited about our project and hope you'll visit our webpage for updates and follow our progress through the blog!

Staying iN Touch with Youth with Obesity and Depression

This post is the third in a series that will introduce you to our five new grantee teams.

By Katherine Kim, San Francisco State University, iN Touch Principal Investigator

Obesity and depression
Overweight and obese youth are suffering from chronic illnesses at younger and younger ages. The iN Touch project is reaching out to youth who are dealing with or are at risk for obesity and depression. Here at San Francisco State University’s Health Equity Institute (SF State) we believe we need to manage both of these conditions to have healthier youth. 

iN Touch
To tackle this issue we have partnered with clinicians from San Francisco General Hospital’s Teen Clinic (SFGH) to integrate smartphone technology with a health coaching model of care to help youth say in touch with their health, in touch with the factors in their environment that impact their health, and in touch with their care team. With an iPhone or an iPod Touch, San Francisco teens will be able to track observations of daily living (ODLs) such as food choices, physical activity, social networks, moods and information about the environment they live in that they feel is relevant to managing their physical and mental health. But, access to information and tracking of ODLs is only a first step. Taking action based on the information is critical. That’s where health coaching comes in.

The SFGH health coaching model centers around the patient. The primary care team includes the physician, therapist, and health coach who work together to support the patient. For example, a health assessment will be done by the physician that identifies medical issues. The health coach will then meet with the patient to help them develop an action plan—one that states the patient’s specific health goal, steps she will take to work towards that goal, and commitments around tracking, communication, and follow through. The smartphone technology supports the daily engagement with the action plan and allows the patient to interface with the health coach as often as they want. It also helps the care team identify medical and mental health issues as they arise, not waiting until the next visit which might be weeks or months away. In this way, we hope to enable an integrated and comprehensive approach to well-being that helps patients and their providers work together.

The iN Touch Team
I am the principal investigator from SF State and work with co-PI Christina Sabee from SF State’s Communications Studies Department. We are collaborating with the SFGH team which includes co-PI (and UC San Francisco faculty) Dr. Tom Bodenheimer, medical director Dr. Hali Hammer, Teen Clinic attending Dr. Aisha Mays, Department of Public Health psychiatric social worker David Guldmann, and iN Touch program manager Amireh Ghorob. We also have great research assistants: health education graduate student Ed Young and communications studies graduate students Joven Chacon and Holly Logan.

We are very excited about our project and hope you'll visit our webpage for updates and follow our progress through the blog!

BreathEasy - A PHR for Adults with Asthma and Depression or Anxiety

This post is the first in a series that will introduce you to our five grantee teams.

By Barbara L. Massoudi, RTI International, BreathEasy Principal Investigator.

Asthma, depression and anxiety
The link between asthma, depression and anxiety has stymied medical researchers for some time. Despite several studies, it’s really unclear which comes first. The mechanism for the interaction between these two conditions is also a mystery – is it behavioral, environmental, or biological? No one really knows.

Managing these conditions
What we do know is that for people with asthma, managing their condition on a daily basis can be challenging. There are several different types of medications that can be taken and avoiding triggers is an important thing to do as well. Triggers are usually things that we all commonly encounter on a daily basis such as animal dander, pollen, smoke, cold air, even physical activity. Add to all this a condition like depression or anxiety that typically makes people less energetic and less likely to be able to do things to care for themselves. The interaction of the two conditions can lead to a vicious cycle, affecting the quality of life for patients.

The BreathEasy project
This difficulty in self-management and the impact on quality of life is exactly why we decided to tackle this complicated set of conditions through our project. Researchers at RTI International, a non-profit research organization and the Virginia Commonwealth University Department of Family Medicine have teamed up to develop a PHR application to assist people with asthma and depression or anxiety. To develop the tool, we’ll work with about 35 adult patients with asthma and depression or anxiety, recruited from the patient populations served by two primary care clinics in Richmond, VA – the Nelson Clinic and the Hayes E. Willis Health Center. The PHR tool will help these patients track observations of daily living (ODLs) related to their conditions. ODLs can be things that you do everyday – such as taking a medication, or things that you feel – like shortness of breath or a sad mood, as well as objective measures of lung function like peak flows. The importance of capturing the ODLs is that they could hold the key to sorting out an individual’s personal experience with triggers, meds, and symptoms, but they don’t occur in the doctor’s office where they can easily be observed. These are things that occur out in the world, in the course of everyday life, and generally speaking, people aren’t very good at recalling things they do, even on a daily basis. The PHR tool will offer a way to capture and display this information in a way that will be informative to the patients and hopefully, clinically relevant to their health care providers.

The project team
As the principal investigator, I’m working with co-PI, Dr. Steve Rothemich from VCU as well as Dr. Alex Krist, another physician in the Department of Family Medicine. The RTI team consists of Bill Savage who will develop the patient application for the Android-based phone, Mike Zmuda, who will build the clinician dashboard, Sarah Cook, who will conduct focus groups and do usability testing with patients and clinicians to learn what features and tools they’d like the application to have, Rita Sembajwe, who will keep me on track with her project management skills, and develop a newsletter for patients, and Lucia Rojas-Smith, who will design an evaluation to measure the impact of the tool on patients, clinicians, quality of care, patient-clinician communications, etc.

We hope you'll visit our webpage for BreathEasy updates and follow our progress through the blog!