Transforming Healthcare Transforming Lives Technology-Based Intervention HeartMapp: A Mobile Phone app for Telemonitoring Support to improve Heart Failure

Transforming Healthcare Transforming Lives

Technology-Based InterventionHeartMapp: A Mobile Phone app for

Telemonitoring Support to improve Heart Failure Outcomes

1

Pon Athilingam, PhD, ACNP, MCH, FAANPMiguel Labrador, PhD. Computer Science & Engineering

Making Life Better®

DisclaimerHeartMapp: A mobile App for Heart Failure

Copyrighted by USF: Ponrathi R. Athilingam Miguel

Labrador

Development was Funded by:The CS

Draper LaboratoryFlorida

High-Tec CorridorNo financial Conflict


Heart Failure Symptoms

• HF: Complex syndrome

• 5.1 million people in US (Go et al., 2014)

• Symptom clusters varies

individually (Moser et al., 2014 )


Heart Failure Self CareHeart 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)


Why is Self-care Important?

• Prevent remodeling: Prevent heart failure from getting worse

• Increase lifespan

• Improve quality of life

• Thereby reduce costly readmissions (Mann & Bristow, 2005)

Heart Failure Management and Self-care are aimed to:


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)


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


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


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

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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)


Integrated mHealth Theoretical ModelThe 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


HeartMapp Architecture


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


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


Features of HeartMapp

Create AccountHeartMapp Disclaimer

• HeartMapp is Copyrighted

• Accept the disclaimer

• Register to use the HeartMapp

• Once registered, patients will have access to all features of HeartMapp


Features of HeartMapp 1. Assessment Memory Heart failure symptoms2. Exercises Walking Breathing3. Vital Sign Monitoring Heart rate Respiratory rate Heart rate variability4. CHF educational information- 10 modules that are audio enabled


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 as well as 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


Assessment: Weight and BP

• Check weight and Blood pressure and record it

• Bluetooth enabled devises will transfer data

automatically


HF Symptom Assessment

Heart failure symptom questions; audio enabled; answers appear randomly


HF Symptom Assessment

Heart failure symptom questions; audio enabled; answers appear randomly


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


Feedback on Symptom Assessment

Colored Zones are classified utilizing New York Heart Association classification


HeartMapp: Exercises ModuleBreathing ExerciseBiofeedback with 6 breath/minIt aims to reset the autonomic system

Measures Predicted distance walked in 6 minutes- based on the Algorithm of Age, Gender, BMI


HeartMapp: Vital Sign MonitoringBioHarness Strap with Bluetooth Sensor

Monitors

• Heart Rate• Resp. rate• HRV• Posture• Coughing• Activity


HeartMapp: CHF Info Module on Education


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.


Beta Testing of HeartMappTable 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%


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


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

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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.


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Transforming Healthcare Transforming Lives Technology-Based Intervention HeartMapp: A Mobile Phone app for Telemonitoring Support to improve Heart Failure