Using mHealth and Patient-Reported Outcomes to Deliver Evidence-Based Asthma Care (Massachusetts)

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Summary:

Asthma affects more than 25 million individuals in the United States, and can lead to morbidity, disruption in lives, hospitalizations, and early deaths. Recent updates to existing guidelines call for providers to adjust treatment based on serial monitoring of patients’ symptoms. Mobile health (mHealth) and smartphone technology can allow patients to report symptoms more frequently and conveniently outside of an office visit, and make those data available to providers. While more than three-quarters of Americans currently own smartphones, mHealth solutions are not widely used to facilitate collection of asthma-related patient-reported outcomes (PROs) for routine use in clinical care.

This research designed an application (app) and practice model for asthma patients using user-centered design principles. The practice model included three components for patients: 1) invitations to participate by their physicians; 2) weekly questionnaires and periodic calls from a nurse; and 3) the ability to view their data graphically. A fourth component of the practice model allowed physicians to access patients’ data from within their electronic health records. The goals of the research were that patients with asthma would complete a questionnaire about their symptoms on a weekly basis; and that providers would find the app clinically beneficial and not burdensome to use. Researchers conducted a 6-month feasibility test in two subspecialty care clinics, and evaluated results through analysis of app usage logs and semi-structured interview data.

The specific aims of the research were as follows:

  • Assess the extent to which patients use the app, and better understand the factors that influence their usage. 
  • Understand the benefits and barriers to integrating the practice model into clinical care from the clinician’s perspective. 
  • Identify opportunities for enhancements to the app and practice model. 

At the end of 6 months, 92 percent of patients were still completing weekly PRO questionnaires, with female and more educated participants having higher rates of completion. Of all questionnaire responses, nearly a quarter qualified for a possible call from a nurse, with over 80 percent receiving at least one call. Interviews with 21 patients suggested that the app was simple and easy to use, increased awareness of their asthma symptoms and “flares,” made them feel more connected to their provider, and avoided emergency care. Providers reported minimal workflow burden. Patients and providers suggested many enhancements, including recording peak flows and details on recent symptoms and treatment.

The researchers found that a simple mHealth app for asthma symptom monitoring can achieve high patient engagement when integrated into clinical care, and identified that enhancements to the intervention would likely be needed to modify for use in primary care. This work may serve as a model for developing mHealth tools and practice models for other chronic conditions.

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Using mHealth and Patient-Reported Outcomes to Deliver Evidence-Based Asthma Care - Final Report

Citation:
Rudin R. Using mHealth and Patient-Reported Outcomes to Deliver Evidence-Based Asthma Care - Final Report. (Prepared by RAND Corporation under Grant No. R21 HS023960). Rockville, MD: Agency for Healthcare Research and Quality, 2018. (PDF, 304.12 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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A Simple Mobile Application is Key to Patient Engagement in Reporting and Monitoring of Asthma Symptoms

Key Finding and Impact:

A simple app, designed with input from patients, resulted in 92 percent of patients continuing to report their asthma outcomes at the end of the study. A tool like this simple app may help patients better control their asthma and prevent emergency care.

Seeing value in using PROs data for research purposes, Dr. Robert S. Rudin from the RAND Corporation recognized that PROs data could also be used to improve patient care. People with asthma have better outcomes and fewer flareups when their symptoms are routinely monitored and managed by clinicians. Using mobile applications to report asthma symptoms to clinicians would allow for more timely management of asthma systems.

Dr. Rudin and his research team designed a patient-facing mobile phone app for people with asthma using user-centered design principles and an iterative process that engaged patients and providers. Patients received a weekly prompt to answer five standardized questions about their current asthma symptoms. A care manager, such as a nurse or medical assistant, received notifications if patient-reported symptoms met specific conditions of worsening severity.

User feedback is important to the development of mobile health apps.

Keeping patients engaged is often a challenge in healthcare; therefore, the research team knew they had to develop an app that would be of value to patients so that they would continue to use it. Dr. Rudin commented, “Using a user-centered design process, the patients reveal to you what they want for the design. I’ve yet to have an interaction with a user where I didn’t learn something.” The user-centered design process informed the development of the app and the practice model for the intervention. For instance, physicians invited their patients to use the mobile app, because the researchers found during the formative research that patients are more likely to adhere to recommendations made by their physicians.

The importance of keeping it simple “Too often we try to load up interventions with bells and whistles, and then you don’t know exactly why it works or doesn't work. For this intervention, we discovered that asking patients five simple questions once a week, with the option to call the provider, kept patients engaged in asthma management and made them feel more connected with their physicians.”
- Dr. Robert S. Rudin

A simple solution to engage patients.

Dr. Rudin and his team conducted a 6-month feasibility study in two subspecialty care clinics, analyzing app usage logs and data from interviews conducted with patients and clinical staff. At the end of 6 months, they were surprised and pleased to find high patient engagement: 92 percent of patients were still completing weekly PRO questionnaires. Over 80 percent of patients received at least one call based on their weekly PRO responses. Patients reported that the app was simple and easy to use, increased awareness of their asthma symptoms and flares, made them feel more connected to their provider, and avoided emergency care. Providers reported minimal workflow burden.

Scale and spread of this successful application and model.

Dr. Rudin has been funded for future work by AHRQ to scale and spread this successful app and practice model. For this current research, Dr. Rudin and his team are applying user-centered design processes to enhance and adapt the app in a primary care setting, where much of asthma disease management occurs. The enhancements will include recording peak flows and details on recent symptoms and triggers, which were suggested by patients and providers during the original research project. The enhanced app and model will be rigorously evaluated with a randomized controlled trial to understand the impact of the app on quality of life and asthma-related healthcare utilization.

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