Digital Health Advisers – The ‘person connection’ in Digital Health.
13 Oct, 2022
my mhealth recognised there was a need to create person-centred digital app delivery and support which led to the development of the DHA.
The NHS is facing continuing pressures with waiting lists at an all-time high(1). The increasing demand reaches across the health system affecting millions of patients and staff, recently exacerbated by the pandemic(2). GP practices across the UK continue to struggle with high demand and a reduction in workforce resulting in a knock-on effect for patients(3). Additionally, NHS hospital trusts are experiencing a backlog of patients leading to long waiting times and overdue appointments(4).
Those who suffer from a long-term health condition such as heart disease, diabetes and respiratory disease who require regular health reviews are unlikely to be receiving the support they need meaning, for the most part, they must manage their health themselves. However, without the skills, knowledge and confidence to self-manage, their health may be at greater risk. Digital health can provide patients and clinicians with an additional tool to create a supported self-management process(5), but many challenges exist with digital implementation on an already overstretched health service.
The digital revolution in healthcare.
Digital health interventions such as wellness, self-care and activity apps have been shown to promote healthy behaviours such as smoking cessation, reduced alcohol intake, support with exercise, and eating a healthy diet(6). Furthermore, recent evidence shows they can improve outcomes for patients with long-term conditions(6)(7)(8)(9), and importantly, they can improve accessibility to health-related information. Pre-pandemic the uptake of digital health technologies was slow(2)(10), however with the emergence of COVID-19, they became an immediate necessity and digital health adoption was greatly accelerated within healthcare service delivery(11)(12). NHS Digital reported a 111% usage increase in NHS app registrations(13).
Despite digital health interventions offering numerous benefits, a great challenge is promoting uptake and engagement(14)(15)(16). Making an App available to clinical teams and patients is unlikely to be enough to drive adoption and engagement. Instead, when deploying a solution, it’s imperative that the local needs of healthcare teams and their patients are considered carefully and a personal approach is taken. To ensure healthcare teams receive the necessary support to implement digital self-management apps with a personal touch, my mhealth created the Digital Health Adviser (DHA).
The Digital Health Adviser.
my mhealth recognised there was a need to create person-centred digital app delivery and support which led to the development of the DHA. By bringing together the technology and the needs of the service the perceived ‘heavy lift’ challenge of a digital transformation project has been reduced.This role works in partnership with my mhealth and the healthcare provider using an honorary contract. The healthcare team provides them with a list of patients to contact and offer the app(s). Those patients who would like to use the app(s) are offered guidance on how to use and are signposted to content related to goals set by the clinical teams. Similarly, the DHA’s support clinicians to engage with the technology, providing them with the skills to support, enhance and scale their service.
Since the creation of this new role, the benefits became evident very quickly. As a result, we now have a team of DHA’s working with NHS healthcare services across the country. They bridge the gap between the digital health platform, the clinician and the patient to support app uptake and engagement. Importantly, they promote digital inclusion and encourage the creation of local community digital champions. Figure 1 shows the increase in app usage for just five NHS sites since the DHA role was implemented.
- Case StudiesIn Mid and South Essex (MSE) DHA support was provided to compliment a drive from the clinical services to engage patients in myDiabetes. This saw an increase in app registrations from 1654 to 6356 users within 2 years, demonstrating a 284% increase. Furthermore, within 1 year in-app education video activity increased from 10,316 to 21,272
- Knowsley saw an increase in app registration from 277 to 3788 following DHA implementation over 2 years (1267% increase)
- Using the DHA, Cambridge and Peterborough CCG provided continuous access to education and self-management support using myAsthma, promoting equal access to the service for the local population. Nine practices with the highest healthcare utilisation were provided with 900 myAsthma licenses. All of these were supplied to patients within 6 months, of which 720 (80%) of patients activated the app.
- Kent and Medway CCG have registered over 6000 patients to the myDiabetes app in support of Structured Diabetes Education, driving a 200% increase in enrolment to the programme in 18 months.
Providing the ‘human’ connection in digital health Studies have shown that providing ‘human’ support in digital health interventions improves patient engagement(17). The DHA is the person-link between digital health apps, clinicians and patient users, providing a structured route for the implementation of digital therapeutics into the NHS at population scale, reaching high levels of user engagement. The interaction of the DHA with clinical teams is vital to increasing confidence in using technology for both clinicians and patients, working towards reducing digital exclusion. The DHA’s are in constant contact with clinical teams to support their service and patients to encourage usage to promote self-management. They are also able to obtain important feedback of how the app(s) are functioning in the real-world. Some comments received from clinical teams are:
“The DHA oversees the smooth running of patients who sign up for the app. They help patients with their many queries, and help the admin team to contact patients to take up the App. I could not do this part of my job without their input. Aside from the obvious impact they have on our patient’s education and management of their health, they are also enthusiastic and have a ‘can do’ attitude which really makes a difference when trying to encourage patients to use the app modules. They make my job much easier. I am so grateful for their help and feel totally supported at all times.” (Healthcare Administrator)
“Working with my mhealth and the DHA’s has been invaluable to our practice. Their help and support has enabled them to give patients an informed choice on how to manage their chronic disease. Not only has this taken pressure off general practice it has given people the tools they need to improve and manage their own health.” (Nurse Specialist)
Feedback from patients receiving DHA support include:
“Without your help I would have been 'out' of the my mhealth app for ever! Thank you so much for your patience and help with getting me started.”
“I have completed the exercises in Lifestyle tile is there another exercise tile or do I repeat what I have already completed? Your help would be appreciated.”
“Thank you for helping me - it's been a life changer for me and you can quote me on that.”
“For me personally to have someone as supportive as the DHA is as and when you need is invaluable. Diabetes is scary I'm still pretty new at finding out but the way your life works around it but with the proactiveness and correspondence and the regular updates from the DHA I don't know where I would be without it.”
As more healthcare services look to benefit from this support, the DHA team is expanding to meet the growing demand. Clinical partners are demonstrating a true step-change in the delivery of digital health to support healthcare delivery at population scale. Importantly, patients are provided with support both digitally and personally to self-manage their long-term condition without losing the human connection with their clinical teams.
References
Gardner T. Pressures on the NHS are far from ‘sustainable’ [Internet]. The Health Foundation. 2021 [cited 2022 Aug 24]. Available from: https://www.health.org.uk/news-and-comment/news/pressures-on-the-nhs-are-far-from-sustainable- Peek N, Sujan M, Scott P. Digital health and care in pandemic times : impact of COVID-19. BMJ Heal Care Informatics [Internet]. 2020;27:1–3. Available from: https://informatics.bmj.com/content/27/1/e100166
- Royal College of General Practitioners. Chronic shortage of GPs is the reason patients are facing long waiting times for appointments [Internet]. RCGP. 2021 [cited 2022 Aug 24]. Available from: https://www.rcgp.org.uk/news/2021/september/chronic-shortage-of-gps-is-the-reason-patients-are-facing-long-waiting-times-for-appointments
- United Lincolnshire Hospitals NHS Trust. Waiting for your outpatient appointment during the COVID-19 Pandemic [Internet]. NHS Trust. 2021 [cited 2022 Aug 24]. Available from: https://www.ulh.nhs.uk/patients/outpatients/waiting-for-your-outpatient-appointment-during-the-covid-19-pandemic/
- Bene BA, O’Connor S, Mastellos N, Majeed A, Fadahunsi KP, O’Donoghue J. Impact of mobile health applications on self-management in patients with type 2 diabetes mellitus: Protocol of a systematic review. BMJ Open. 2019;9(6).
- Murray E, Hekler EB, Professor A, Andersson G, Collins LM, Doherty A, et al. Evaluating digital health interventions: key questions and approaches HHS Public Access Background & Aims. Am J Prev Med [Internet]. 2016;51(5):843–51. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5324832/pdf/nihms850074.pdf
- Murray E, Ross J, Pal K, Li J, Dack C, Stevenson F, et al. A web-based self-management programme for people with type 2 diabetes: the HeLP-Diabetes research programme including RCT. Program Grants Appl Res. 2018;6(5):1–242.
- Crooks MG, Elkes J, Storrar W, Roy K, North M, Blythin A, et al. Evidence generation for the clinical impact of myCOPD in patients with mild, moderate and newly diagnosed COPD: a randomised controlled trial. ERJ Open Res [Internet]. 2020;6(4):00460–2020. Available from: http://dx.doi.org/10.1183/23120541.00460-2020
- Nabutovsky I, Nachshon A, Klempfner R, Shapiro Y and TR. Digital Cardiac Rehabilitation Programs: The Future of Patient-Centred Medicine. Telemed e-Health [Internet]. 2020;26(1):34–41. Available from: https://www.liebertpub.com/doi/10.1089/tmj.2018.0302#:~:text=These programs imply a high level of patient,no significant differences in mortality or hospitalizations
- Pillay R. Digital Health Trends [Internet]. 2021. Available from: https://www.iqvia.com/-/media/iqvia/pdfs/institute-reports/digital-health-trends-2021/iqvia-institute-digital-health-trends-2021.pdf?&_=1630938621119
- National Diabetes Audit. Improving attendance and data recording for structured education. 2018; Available from: https://www.diabetes.org.uk/resources-s3/2018-12/SE Guidance_ v3.pdf
- DESMOND. MyDESMOND eLearning Platform [Internet]. 2019 [cited 2020 Sep 25]. Available from: https://www.desmond-project.org.uk/portfolio/mydesmond-elearning-platform/
- Poinasamy K. Useful Digital Health Apps and Platforms [Internet]. BLF and Asthma UK. 2022 [cited 2022 Feb 7]. Available from: https://www.asthma.org.uk/support-us/campaigns/campaigns-blog/useful-digital-health-apps-and-platforms/
- McGowan PT. Self-Management Education and Support in Chronic Disease Management. Prim Care Clin Off Pract [Internet]. 2012;39(2):307–25. Available from: https://www.sciencedirect.com/science/article/abs/pii/S009545431200019X?via%3Dihub
- Murray E, Sweeting M, Dack C, Pal K, Modrow K, Hudda M, et al. Web-based self-management support for people with type 2 diabetes (HeLPDiabetes): Randomised controlled trial in English primary care. BMJ Open. 2017;7(9):1–11.
- Torous J, Myrick KJ, Rauseo-Ricupero N, Firth J. Digital mental health and COVID-19: Using technology today to accelerate the curve on access and quality tomorrow. JMIR Ment Heal. 2020;7(3):1–6.
- Ritterband LM, Thorndike FP, Cox DJ, Kovatchev BP, Gonder-Frederick LA. A behavior change model for internet interventions. Ann Behav Med. 2009;38(1):18–27.
About my mhealthmy mhealth’s digital therapeutics have been prescribed to over 80,000 patients with chronic conditions, resulting in reduced morbidity and hospital admissions. It serves patients across a range of long term conditions, including COPD, asthma, diabetes and cardiovascular disease. Our flagship product, myCOPD, was the exclusive digital therapeutic deployed by the UK’s NHS to deliver pulmonary rehabilitation during the pandemic, when in person care was practically inaccessible. Real world and clinical trial evidence demonstrates the efficacy of digital interventions on the my mhealth platform.
For more information on my mhealth, visit www.mymhealth.com.
Permission to use received from Rebecca Fowler View poster .
Results of a service evaluation using myHeart in a large London-based acute NHS Trust. We are pleased to report the outcomes from this recent service evaluation of myHeart and the potential benefit of using the myHeart app to supplement existing cardiac rehabilitation (CR). Cardiac rehabilitation is an essential evidence-based intervention that supports patient recovery following a cardiac event. It offers patients a structured education and exercise programme to aid recovery and support behavioural changes to help reduce the risk of future cardiac health complications. The myHeart app provides a structure educational and exercise intervention that mirrors current CR service delivery as well as supportive self-management tools. Overall, 721 patients were invited to participate in 1 of 4 groups (class-based CR, class-based CR with myHeart, home-based CR and home-based CR with myHeart). A total of 584 patients opted to use class-based CR and of these 43 chose to include myHeart to support them with this. There were 137 patients in the home-based group, with 54 choosing to include myHeart alongside their CR. This 12-week evaluation involved functional, physical and psychological assessments both before and after CR to explore potential changes. Patients were also asked to complete a rating of perceived exertion Borg RPE scale (Borg 6-20). Those in the home-based groups were contacted mid-way through the study. Results identified three key outcomes: 1. Blood pressure, cholesterol, LDL, BMI, HbA1c and exercise were all very similar across the groups with marginal differences across each measure. 2. Drop-out rates (DOR) of patients being invited to attend CR and attending CR were significantly lower in those groups with access to myHeart. * Class only: DOR = 58.2% Class + App; DOR = 25.6% * Home only: DOR = 73.5% Home + App; DOR = 42.6% 3. Those patients with access to myHeart and in the home-based group saw the greatest improvement in anxiety and depression scores. This real-world evaluation provides an encouraging insight into the potential impact of myHeart to supplement CR services, and is suggestive that, as an adjunct to support both class and home-based programmes, myHeart helps to reduce drop-out rates in CR and can assist in reinforcing continuous engagement with CR programmes.
Results have led to continued QISMET Accreditation for myDiabetes (QIS2015) and have revealed the app could play an important role in supporting structured patient education delivery for type 2 diabetes following initial diagnosis, and as an ongoing resource. Together with a large Health and Care Partnership, we led a multi-centre service evaluation to explore the impact of myDiabetes on education course attendance rates. T2DM is a serious and growing problem worldwide and affects more than 3 million people in the UK. Structured education is a large part of managing T2DM to promote a healthy lifestyle and improve blood sugar control. However, the uptake for education courses has been less than encouraging across the UK. By offering a digital alternative or adjunct to a class-based course those who are unable or prefer not to attend a class-based programme, are able to receive structured education. myDiabetes is an app to support patients and clinicians manage diabetes together, remotely and at scale. Overall, 83 T2DM patients were recruited by the healthcare team, of which 28 chose to use myDiabetes alone, 35 chose only usual care, and 20 chose to use both. Patient education usage was monitored over a 12-week period. During this evaluation we monitored changes in diabetes related clinical health outcomes where possible, including HbA1c, blood pressure and body mass index. Participants in all three sites were asked to complete the Problem Areas In Diabetes (PAID) questionnaire at the beginning and end of the evaluation to explore markers of improvement in diabetes related distress. Results showed the app was acceptable in this care setting with 31 of 42 patients using it alone or as an adjunct to usual care. A total of 586 education videos were watched, on average each patient watched 22.5 (SD 19.6) videos. There was a reduction in PAID scores across all arms, with the app only arm showing the greatest improvement. Patients using myDiabetes showed the greatest improvement in HbA1c (-7.5 vs –4.4 mmol/mol), Systolic Blood Pressure (-12.2 vs +3.3 mmHg) and PAID score (-6.8 vs –5.2). In this real world evaluation myDiabetes performed better than published education course completion rates and resulted in significant improvements in HbA1c and PAID score compared to classed-based programs. This supports the use of myDiabetes to support the delivery of structured based education for patients with type 2 diabetes.
NHS University College London Hospitals NHS Foundation Trust, part of North Central London ICB, is taking a significant step towards enhancing patient empowerment and optimising disease management. Asthma is a chronic condition that affects millions of people worldwide, often leading to severe health complications if not managed properly. Recognising the critical need for effective self-management tools, NHS University College London Hospitals NHS Foundation Trust has chosen the myAsthma app to provide patients with the resources they need to take control of their health. Dr Kay Roy PhD FRCP, Consultant Respiratory Physician University College London Hospitals NHS Foundation Trust, comments “We are thrilled to introduce myAsthma as a self-management tool to our community. It represents a significant step forward in empowering our patients with asthma to take control of their health. By providing them with personalised support, we believe this tool will greatly improve their quality of life. Additionally, the use of myAsthma in outpatient settings will help triage patients more effectively, ensuring they are seen in a timely manner and appropriately referred for the right investigations and services. Our team is excited to see the positive impact this will have on the asthma population across North Central London ICB." The myAsthma app, part of the my mhealth suite of digital health solutions, is designed to empower patients with comprehensive tools and information to manage their asthma more effectively. Key features include: • Personalised Action Plans: Tailored asthma management plans based on individual patient needs. • Inhaler technique training: Contributing to better health outcomes and reduced risk of exacerbations • Medication Tracking: Reminders and logs to ensure patients take their medication as prescribed. • Symptom tracking: Easy-to-use tools for tracking symptoms and triggers. • Educational Resources: Access to a wealth of information on asthma, helping patients understand their condition and how to manage it. As more NHS partners embrace the my mhealth platform, we're thrilled to witness its growing impact and the positive changes it is bringing to long-term condition care. For more information on this article or other my mhealth projects, please get in touch https://mymhealth.com/contact-us
Read the myCOPD Data Booklet.
Permission to use received from Rebecca Fowler View poster
Henry M.G. Glyde1Alison M. Blythin2 Tom M.A. Wilkinson3Ian T. Nabney4 James W. Dodd5 EPSRC Centre for Doctoral Training in Digital Health and Care, University of Bristol, Bristol, UK my mHealth Limited, Bournemouth , UK my mHealth and Clinical and Experimental Science, University of Southampton, Southampton, UK School of Engineering Mathematics and Technology, University of Bristol, Bristol, UK Academic Respiratory Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK Abstract Background Acute exacerbations of COPD (AECOPD) are episodes of breathlessness, cough and sputum which are associated with the risk of hospitalisation, progressive lung function decline and death. They are often missed or diagnosed late . Accurate timely intervention can improve these poor outcomes. Digital tools can be used to capture symptoms and other clinical data in COPD. This study aims to apply machine learning to the largest available real-world digital dataset to identify AECOPD Prediction tool which could be used to support early intervention improve clinical outcomes. Objective To create and validate a machine learning predictive model that forecasts exacerbations of COPD 1-8 days in advance. The model is based on routine patient-entered data from myCOPD self-management app. Method Adaptations of the AdaBoost algorithm were employed as machine learning approaches. The dataset included 506 patients users between 2017-2021. 55,066 app records were available for stable COPD event labels and 1,263 records of AECOPD event labels. The data used for training the model included COPD assessment test (CAT) scores, symptom scores, smoking history, and previous exacerbation frequency. All exacerbation records used in the model were confined to the 1-8 days preceding a self-reported exacerbation event. Results TheEasyEnsemble Classifier resulted in a Sensitivity of 67.0% and a Specificity of 65% with a positive predictive value (PPV) of 5.0% and a negative predictive value (NPV) of 98.9%. An AdaBoost model with a cost-sensitive decision tree resulted in a a Sensitivity of 35.0% and a Specificity of 89.0% with a PPV of 7.08% and NPV of 98.3%. Conclusion This preliminary analysis demonstrates that machine learning approaches to real-world data from a widely deployed digital therapeutic has the potential to predict AECOPD and can be used to confidently exclude the risk of exacerbations of COPD within the next 8 days. Permission to use received from Henry Glyde. Read more on Heliyon website.
Charlotte Smith 1 Francesca D’angelo 2 University Hospital of Derby and Burton, Cardiac Rehabilitation Department, Burton Upon Trent, UK. University Hospital of Derby and Burton, Health and Wellbeing Department, Burton, UK To examine the effectiveness of physical activity outcomes using a web-based Cardiac Rehabilitation application compared with a conventional programme or a combination of both. University Hospitals of Derby and Burton NHS Foundation Trust poster presented at the BACPR Annual Conference October 5-6th 2023 Permission to use received from Charlotte Smith
Francesca D’angelo 1 Charlotte Smith 2 University Hospital of Derby and Burton, Health and Wellbeing Department, Burton, UK University Hospital of Derby and Burton, Cardiac Rehabilitation Department, Burton Upon Trent, UK. To examine the effectiveness of psychological outcomes using a web-based Cardiac Rehabilitation application compared with a conventional programme or a combination of both. University Hospitals of Derby and Burton NHS Foundation Trust poster presented at the BACPR Annual Conference October 5-6th 2023 Poster presented at the BACPR Annual Conference October 5-6th 2023 Permission to use received from Charlotte Smith
Christopher Duckworth 1 Bethany Cliffe 2. Brian Pickering 1 Ben Ainsworth 2 Alison Blythin 3 Adam Kirk 3 Adam Kirk Thomas M. A. Wilkinson 3,4,5 Michael J. Boniface 1 1 IT Innovation Centre, Digital Health and Biomedical Engineering, University of Southampton, Southampton, UK. 2. School of Psychology, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK my mHealth Limited, London, UK. National Institute for Health Research Applied Research Collaboration Wessex, University of Southampton , Southampton , GB Faculty of Medicine, University of Southampton, Southampton , GB Mobile Health (mHealth) has the potential to be transformative in the management of chronic conditions. Machine learning can leverage self-reported data collected with apps to predict periods of increased health risk, alert users, and signpost interventions. Despite this, mHealth must balance the treatment burden of frequent self-reporting and predictive performance and safety. Here we report how user engagement with a widely used and clinically validated mHealth app, myCOPD (designed for the self-management of Chronic Obstructive Pulmonary Disease), directly impacts the performance of a machine learning model predicting an acute worsening of condition (i.e., exacerbations). We classify how users typically engage with myCOPD, finding that 60.3% of users engage frequently, however, less frequent users can show transitional engagement (18.4%), becoming more engaged immediately ( < 21 days) before exacerbating. Machine learning performed better for users who engaged the most, however, this performance decrease can be mostly offset for less frequent users who engage more near exacerbation. We conduct interviews and focus groups with myCOPD users, highlighting digital diaries and disease acuity as key factors for engagement. Users of mHealth can feel overburdened when self-reporting data necessary for predictive modelling and confidence of recognising exacerbations is a significant barrier to accurate self-reported data. We demonstrate that users of mHealth should be encouraged to engage when they notice changes to their condition (rather than clinically defined symptoms) to achieve data that is still predictive for machine learning, while reducing the likelihood of disengagement through desensitisation. Read more
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