iCAN Self-Management Technology

Helping Patients Adhere to Medical Appointments

June 20, 2014

Maen Mahfoud - MPH

Agenda1. The Problem

3. The Intervention - iCAN

4. Implementation & Evaluation

2. Causes & Rationale

5. Challenges

‘Missing appointments cost the NHS above £600 million per year, enough to run two medium-size hospitals.’ BBC 2009

Rate of non-attendance in the UK is 12%. Cost: disrupt the flow, interfere with the continuity of healthcare

Directly: through underutilization of administrative resources

Indirectly: through increasing hospital readmission rate.

The Problem

(William Hamilton et al., 2002)

(Neal et al., 2005)

Causes

Patient Disengagement

Current Interventions

Incentives / Fines Overbooking

Phone Reminders SMS Reminders

Postal Reminders Online Consultation

Example 1: DAWN Project

Number of Number of Webcam Webcam

AppointmentsAppointmentsNumber of DNAsNumber of DNAs DNA RatesDNA Rates

Software provider 1 137 41 30%

Skype 37 6 16%

OverallOverall174 174

Appointments Appointments (68 Patients)(68 Patients)

4747 27%27%

Diabetes Appointments via Webcam in Newham

Design a Patient-Centered environment

iCAN : self-management tool

Solution

iCAN takes insight from:

1. Disruptive innovation

2. Nudge Theory

3. MIND SPACE

4. Patient-centered design

Rationale

1. Disruptive Innovation

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‘Will Disruptive Innovations Cure Healthcare?’ Harvard Business Review (Christensen, 2000)

Bending the cost curve through self-management

Rationale

2. Nudge Theory Rationale

3. MINDSPACE Rationale

3. MINDSPACE Rationale

4. Patient-Centered Design

Patient role is passive

Patient is the recipient of treatment

Physician dominates the conversation

Care is disease-centered

Physician does most of the talking

Patient may or may not adhere to

regimen

Patient role is Active

Patient is a partner in the treatment plan

Physician collaborates with the

patient

Care is quality-of-life centered

Physician listens more & talk lessPatient is more

likely to adhere to regimen

(Fusions, 2011)

Rationale

Rationale

Synthesis

The Intervention

iCAN is an electronic self-management tool aimed to provide an engaging environment for diabetic outpatients to gain control over their health, and ultimately adhere to their medical appointments.

iCAN Framework

IMMERSEPatients will be immersed in their health by using iCAN technology

CONTROLPatients will gain control of their environment

ADHEREPatients will adhere and commit to showing up and take medication

NETWORKPatients will be able to share their concerns via iCAN forum & Chat rooms

iCAN User Interface Design & Delivery

Resources & CostsLocation: Newham University Hospital NHS Trust in Painstow

DAWN Success & Cost-effectiveness

Poor Outcome & Very HIGH DNAs

Cost

DAWN: Modest short-term savings ~ £ 3000/yr/hospital, promising long-term savingsBrisbane Tele-Pediatrics : Cost-effective, reduced cost by approx. £ 333,000

Implementation & Evaluation

Software Dev: £30,000 – 50,000Equipment+ Installation: £350,000

Pilot Timeline

If SUCCESS, document & standardize practice, if FAILURE, new

approach

Gather a team that has knowledge of DNAs &

Describe AIM statement

Assess Improvement using

evaluation indicators

Implement action plan & Collect data to assess evaluation

l

•12 months pilot study

•50 patients to participate

•Cyclical & iterative using PDSA model.

•3 months will be dedicated for each of the 4 stages.

Implementation & Evaluation

IndicatorsIndicators OutcomeOutcome MethodsMethods TimeTime

UtilizatioUtilizationn

Patient Use Survey Online questionnaires

Focus groups Interviews

(Qualitative Research)

Monthly for a year

Patient Satisfaction

ImpactImpact

Number of DNAs

Pre/Post Intervention Design

#of DNAs via EHR &iCAN Database

Once every 3 month

(f/up for a year)

HA1C Levels

Quasi -experimental design:

Cohort 1: uses iCANCohort 2: uses traditional

Once every 3 month

(f/up for a year)

Implementation & Evaluation

Limitations & Discussion

Recommendation: Invest inSimple, scalable, cheap & frugal technologies

Availability

Accessibility

Acceptability

Challenges

‘ A surge in digital health investing reflects how rapidly confidence in this space is growing. We can clearly see a future where a doctor’s prescription sends you to an immersive online experience as often as it does to a pharmacy.’

Sean Duffy, CEO and Co-Founder, Omada Health

Tele-appointments cost in Brisbane

Appendix A

IMMERSEPatients will be immersed in their health when using this

application. By signing in to this software, the program will: •Send patients reminders about their appointments;•Enforce positive behaviour changes through other users success stories;•Empower patients by educating them about their condition;•Encourage exercise through community forums; •Engage with providers through accessible promotion links;•Inform patients about appointments through calendar alerts;•Eliminate fear associated with medicine through shared experiences in chat rooms;•Provide a user-friendly calendar to encourage people to set schedules and improve their efficiency.  CONTROL

Patients will gain control of their environment; the platform will allow them to:

•Avoid waiting times in hospitals;•Feel in control by meeting from their homes or offices;•Avoid negative emotions about hospitals, GPs, and clinics;•Choose a time that does not interfere with their commitments;•Choose their preferred physician, hence increasing responsiveness; •Have clear expectations about their provider’s role in their health

ADHEREiCAN will use the following techniques to improve

adherence among diabetics:  •Show the risks of not controlling glucose appropriately through the educational links provided;•Make patients sign a contract to show commitment to attend appointments;•Prime participants with motivational pictures (athletes, alerts, medication) to encourage adherence;•Show success stories of patients who are leading healthy lives.  NETWORK

The software will foster networking by enabling patients to:•Communicate with other patients and share concerns;•Learn new methods to cope with appointments and medication;•Organize socials events and perhaps exercise with each other;•Network and exchange useful links and articles;•Motivate each other to take challenges

References BBC. 2009. 'No shows' cost the NHS millions BBC News, 19/4/2014.CHRISTENSEN, C. 2000. Will Disruptive Innovations Cure

Healthcare? [Online]. Harvard Business Review. Available: http://hbr.org/web/extras/insight-center/health-care/will-disruptive-innovations-cure-health-care-sb2 [Accessed 1/5/2014.

CHRISTENSEN, C. 2000. Will Disruptive Innovations Cure Healthcare? [Online]. Harvard Business Review. Available: http://hbr.org/web/extras/insight-center/health-care/will-disruptive-innovations-cure-health-care-sb2 [Accessed 1/5/2014.

DOLAN, P., HALLSWORTH, M., HALPERN, D., KING, D. & VLAEV, I. 2009. MIND SPACE: Influencing behaviour through public policy. UK: Institute For Government.

DUFFY, S. 2014. What If Doctors Could Finally Prescribe Behavior Change? [Online]. Forbes. Available: http://www.forbes.com/sites/sciencebiz/2014/04/17/what-if-doctors-could-finally-prescribe-behavior-change/ [Accessed 2/5/2014.

SHINE. 2011. Newham University Hospital NHS Trust: Web based outpatient consultations in diabetes [Online]. The Health Foundation: Inspiring Improvement Available: http://www.health.org.uk/areas-of-work/programmes/shine-eleven/related-projects/newham-university-hospital/ [Accessed 1/5/2014.

SMITH, A. C., SCUFFHAM, P. & WOOTTON, R. 2007. The costs and potential savings of a novel telepaediatric service in Queensland. BMC Health Serv Res, 7, 35.

WILLIAM HAMILTON, BARNFIELD HILL SURGERY, MANJO LUTHRA, SMITH, T. & EVANS, A. P. 2002. Non-attendance in general practice: a questionnaire survey. Primary Health Care Research and Development, 3.

WM, B. 1980. Failed appointments. Who misses them, why they are missed, and what can be done. Prime Care, 4.