Technology-Based Intervention HeartMapp: A Mobile Phone app for Telemonitoring Support to improve Heart Failure Outcomes Pon Athilingam, PhD, ACNP, MCH, FAANP Miguel Labrador, PhD. Computer Science & Engineering Transforming Healthcare Transforming Lives 1 Disclaimer HeartMapp: A mobile App for Heart Failure Copyrighted by USF: Ponrathi R. Athilingam Miguel Labrador Development was Funded by: The CS Draper Laboratory Florida High-Tec Corridor No financial Conflict Making Life Better® Heart Failure Symptoms • HF: Complex syndrome • 5.1 million people in US (Go et al., 2014) • Symptom clusters varies individually (Moser et al., 2014 ) Making Life Better® Heart Failure Self Care Heart failure patients are expected to: • Remember complex information • Practice Daily self-care • Daily weight • Follow complex medication regimen • Follow low salt diet • Understand and manage heart failure symptoms • Exercise regularly • Manage other diseases (Yancy et al., 2013) Making Life Better® Why is Self-care Important? Heart Failure Management and Self-care are aimed to: • Prevent remodeling: Prevent heart failure from getting worse • Increase lifespan • Improve quality of life • Thereby reduce costly readmissions (Mann & Bristow, 2005) Making Life Better® Current Strategies to Improve Outcomes • Get with guidelines (Go et al., 2014) • Improve performance measures (Heidenreich et al., 2013) • Focused on best practice models • Follow Pathways and algorithms • Have discharge order set • Patient education tools • However: no sustained benefit in reducing readmission rate • 25% in 30-days • 50% within 6-months (Go et al., 2014) Making Life Better® Technology Use by Older Adults • 79% of Internet users accessed the internet through their mobile phone in 2014 • 98% of text messages are read, compared to 22% of emails on the computer • Text messages are usually read within the first five seconds of being received • Once older adults >65 years join the online world, digital technology often becomes an integral part of their daily lives Making Life Better® Mobile Technology Application • Mobile technology is defined as devices (Mobile phones and tablets) that are intended to be always be on and carried by the person throughout the day for the purpose of communication during normal daily activities. • Thus available whenever and wherever the individual is • Potential to enhance persistent use of materials presented unlike current paper version of educational materials Making Life Better® Mobile Phone Application to Improve Self-care and HF Outcomes • Technology has exploded within the last decade. • HeartMapp, a Mobile Phone Application for Heart Failure is developed in collaboration with Dr. Miguel Labrador, Professor, Department of Computer Engineering Making Life Better® Theoretical Model for HeartMapp (mHealth) • The Successive Approximation Model (SAM) was used throughout the design and development phases of the application, for both the instructional content and media (Allen & Sites, 2012). • Research on adult learning and engagement suggests that an adult’s engagement in learning activities could increase persistence and involvement (Illeris, 2002). • Yang’s holistic theory of knowledge and learning that suggests engagement and learning are integrated processes by which adult learners gain a deeper understanding and make meaning of the activities he or she is exposed to in a given learning environment (Yang, 2003) The Future Of Pharmacy Is Here Integrated mHealth Theoretical Model The integrated mHealth theoretical model builds on the currently available models and theories and expands to include • The Mayer’s Cognitive Theory of Multimedia Learning and theory of problem-based learning promotes engagement by working collaboratively with patient and family. • Self-care influenced by individual, family, community, and systems. • Self-care as a process in the contexts of knowledge of pathophysiology of HF • Self-care skills needed in HF Making Life Better® HeartMapp Architecture Making Life Better® Hypothesis for Developing HeartMapp • Mobile technology, particularly mobile health (mHealth) for education and self-care skill development could offer persistent engagement and utility of educational materials presented over a prolonged period. • HeartMapp encourages persistent involvement and engagement of patients’ daily self-care activities to potentially improve HF outcomes. • HeartMapp could offer constant companion and will be like a coach or buddy Making Life Better® Method/Design Used • Patient centered approach was utilized • Alpha and beta settings were done during the development phase • Based on feedback from patients and providers -refinements were added to the HeartMapp Making Life Better® Features of HeartMapp • HeartMapp is Copyrighted • Accept the disclaimer • Register to use the HeartMapp • Once registered, patients will have access to all features of HeartMapp HeartMapp Disclaimer Create Account Making Life Better® Features of HeartMapp 1. Assessment Memory Heart failure symptoms 2. Exercises Walking Breathing 3. Vital Sign Monitoring Heart rate Respiratory rate Heart rate variability 4. CHF educational information- 10 modules that are audio enabled Making Life Better® Clinical Features of HeartMapp • Patient engagement tool including audio/video enabled HF information to enhance knowledge • Automation of clinical protocol • HF symptom assessment utilizing the NYHA Classification to determine severity of HF and feedback using colored zones • Feedback on physical activity utilizing distance walked in six minutes based on age, gender, and BMI • Biofeedback for deep breathing exercise • Remote physiological monitoring of heart rate, respiratory rate, and heart rate variability utilizing Bluetooth sensors • Clinical support decisions by offering feedback to patients ® Life Better as well asMaking providers based on real time data. Assessment: Memory Testing • Test of memory/exercise • Presents picture of the Day Three pictures Occur randomly Different ones each day • HeartMapp Includes a Library of pictures over 50 Making Life Better® Assessment: Weight and BP • Check weight and Blood pressure and record it • Bluetooth enabled devises will transfer data automatically Making Life Better® HF Symptom Assessment Heart failure symptom questions; audio enabled; answers appear randomly Making Life Better® HF Symptom Assessment Heart failure symptom questions; audio enabled; answers appear randomly Making Life Better® Assessment: Memory Testing • Nine pictures appear randomly from the library of 50 pictures • If heart function is normal, they may be able to remember all Making Life Better® Feedback on Symptom Assessment Colored Zones are classified utilizing New York Heart Association classification Making Life Better® HeartMapp: Exercises Module Breathing Exercise Biofeedback with 6 breath/min It aims to reset the autonomic system Measures Predicted distance walked in 6 minutes- based on the Algorithm of Age, Gender, BMI Making Life Better® HeartMapp: Vital Sign Monitoring BioHarness Strap with Bluetooth Sensor Monitors • • • • • • Making Life Better® Heart Rate Resp. rate HRV Posture Coughing Activity HeartMapp: CHF Info Module on Education Making Life Better® Alpha and Beta Testing of HeartMapp • Beta testing (N=10): mean age of 63 years • 60% were 65 years of age or older. • All ten of the participants were employed full time • 60% men • 70% Caucasian • 40% lived alone • Ejection fraction is 32.3 ± 12.05% • 90% having systolic HF with ejection fraction <40% • 60% were in New York Heart Association functional classification II • All 100% owned a mobile phone, 50% smartphones • 50% used text messaging • 60% reported using mobile phone very well and 40% fairly well. Making Life Better® Beta Testing of HeartMapp Table 3: Beta Testing Results Percentage Heart Failure tutorial was educational and engaging 100% Learned something new from this tutorial that they did not previously know. 67% Interactive tutorial found them to be engaging and helpful. 100% Interactive activities were related to the Heart Failure subject. 100% Navigation through the modules are easy 100% Addition of Avatar is found to be helpful 100% The scenarios are found to be helpful and engaging 100% The audio was found to be helpful and engaging 100% Making Life Better® Research Goal and Clinical Implication • Currently HeartMapp is being refined • Pilot testing HeartMapp in a clinical trial to compare with existing Telemonitoring service: • explore safety and efficacy of HeartMapp • explore if these technology-based interventions will improve self-care, knowledge, adherence, and quality of life. • explore if HeartMapp interventions will reduce costly hospital readmissions by early intervention Making Life Better® Research Goal and Clinical Implication • • • • Design: Proposed a randomized control clinical trial Compare HeartMapp with existing telemonitoring services Follow patient at 30-days, 3- and 6-months Outcomes: • Self-care • Medication adherence • HF knowledge test • Quality of life • Physiological parameters • Self-confidence in using HeartMapp • Usability questionnaire of HeartMapp • Hospital readmission and ER visit data Making Life Better® References • Allen MW, Sites RH. (2012). Leaving ADDIE for SAM. An Agile Model for Developing the Best Learning Experiences. Danvers, MA: American Society of Training and Development Press. • Enright PL, Sherrill DL. Reference equations for the six-minute walk in healthy adults. Am J Resp Crit Care Med. 1998; 158:1384-1387. • Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics--2014 update: a report from the American Heart Association. Circulation. 2014;129:e28-e292. • Heidenreich PA, Albert NM, Allen LA, et al. Forecasting the impact of heart failure in the United States: a policy statement from the American Heart Association. Circ Heart Fail. 2013;6:606-19. • Illeris K. The three dimensions of learning: Contemporary learning theory in the tension field between the cognitive, the emotional and the social. Copenhagen: Roskilde University. : Niace Publication; 2002. • Mann DL, Bristow MR. Mechanisms and models in heart failure: the biomechanical model and beyond. Circulation 2005;111:2837-49. • Moser DK, Lee KS, Wu JR, et al. Identification of symptom clusters among patients with heart failure: An international observational study. Int J Nurs Stud. 2014;51:1366-72. • Yancy CW, Jessup M, Bozkurt B, et al. 2013 ACCF/AHA guideline for the management of heart failure: executive summary: A report of the American College of Cardiology Foundation/American Heart Association Task Force on practice guidelines. Circulation 2013;128:1810-52. • Yang B. Toward a holistic theory of knowledge and adult learning. Human Res Develop Rev. 2003;2:106-29. The Future Of Pharmacy Is Here Making Life Better®