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Colonel Ronald Poropatich, M.D., USA

Colonel Ronald Poropatich, M.D., USA, U.S. Army Medical Research and Materiel Command, Deputy Director, Telemedicine and Advanced Technology Research Center, Department of the Army, U.S. Department of Defense

Chairman Michaud, Representative Brown, members of the committee thank you for this opportunity to discuss the U.S. Army Medical Department current mobile health projects, future initiatives and challenges in implementing wireless technology across health care organizations.

The U.S. Army recognizes that mobile devices represent an enormous opportunity for healthcare outreach, not only within the active duty and dependent population, but also within the global community.  Globally, there are currently over 4.6 billion cell phones and approximately sixty percent of the world’s population owns cell phones.  Social networks, too, have come to go hand in hand with mobile devices.  Facebook has surged past Yahoo! as the second most popular site in the U.S., drawing nearly 400 million visitors.  Statistics also show that more people access social networks using the mobile web than they do using desktop computers.  Mobile devices are superseding desktop and even laptop computers as the tool of choice for communication in the virtual sphere.

Mobile health or “mHealth”—defined broadly as emerging mobile communications and network technologies for healthcare systems—can be an agent for behavior change, impacting healthcare challenges such as smoking cessation, diabetes, and appointment attendance.  Applications for cell phone and smart phone platforms are emerging that enable clinical consultation, patient and provider education, research, biosurveillance, and disease management. 

The development, implementation and maintenance of any mobile cell phone solution presents a number of innovations, challenges and solutions not widely seen in other aspects of telemedicine.   Wireless device and carrier credentialing and certification, lack of interoperability, Health Insurance Portability and Accountability Act (HIPAA) considerations, and maintaining currency in an ever-changing landscape of devices and operating systems requires strategic planning and long range focus.  There are numerous current obstacles and challenges to launching a comprehensive mobile solution, yet many successes are evident.  Today I would like to discuss three initiatives the U.S. Army’s Telemedicine and Advanced Technology Research Center is currently investigating to improve patient outreach and health outcomes using wireless technology.

The U.S. Army has developed, deployed, and is currently evaluating a mobile telephone-based secure messaging system called “mCare”.  The “m” in mCare stands for mobile.  The project explores the potential of mobile devices, specifically personal cell phones, for use in the Military Healthcare System.  The mCare system is a secure, HIPAA compliant, bi-directional messaging system that allows information to be sent to the service member’s personal cell phone. The Soldiers’ responses are returned securely to the mCare web portal. Presently, mCare provides daily messages via cell phone to wounded Warriors in the outpatient phase of their recovery, while they are recuperating in their homes.  The service members’ own personal cell phones are utilized. 

Patients with mild traumatic brain injury are a target population for mCare.   Health tips, appointment reminders and general announcements are distributed from a secure central website where healthcare providers can enter and control message content, as well as review acknowledgements and delivery confirmations.  Each mCare patient receives a minimum of 6 messages per week, meeting or exceeding the U.S. Army’s required contact rates for wounded Warriors receiving outpatient care in their home communities. 

The initial group of mCare’s targeted participants are Warriors in Transition (WTs) assigned to Community Based Warrior in Transition Units (CBWTUs).  Soldiers  assigned to a CBWTU are typically National Guard or Army Reservists who receive outpatient care in their home community and are monitored remotely by a case manager/care team from a regional case management center.  mCare is not intended to replace all face-to-face or telephone based encounters from the CBWTU team, rather it is designed to complement these efforts with additional means of communication.  Initially mCare has been offered to patients assigned to 5 selected CBWTU sites in Alabama; Florida; Illinois; Massachusetts; and Virginia that cover 26 states.  Future locations for mCare are being explored at this time at 4 additional sites.

The mCare system incorporates modified commercial off the shelf technologies under the oversight of the U.S. Army Medical Research and Material Command’s Telemedicine and Advanced Technology Research Center.  During the development of mCare particular attention was paid to network security and privacy considerations.  Information that is sent to the Soldier’s mobile phone is transmitted through a secure Virtual Private Net (VPN) tunnel, and is only accessible with a six-digit personal identification number (PIN) code.  Cell phone users are prompted to open this application through a standard text message whenever critical new information has been sent to the mCare application. 

As of 1 June 2010, mCare has delivered over 18,500 messages to over 300 WTs.  Sixty-three percent of this message activity is related to appointment reminders, which are sent to the patient 24 hours and 90 minutes prior to each scheduled clinical encounter.  The system has demonstrated improvement in appointment attendance rates.  Seventeen percent of the message activity is attributed to health and wellness tips, which are customized to the needs of each patient from a library of validated resources within the mCare application.  Twelve percent of the message traffic is related to unit specific announcements.

There has been no appreciable age bias to the acceptance of mCare by patients; there are as many users over the age of 30 participating in the project as are within the 18-30 age groups.  Additionally, 84% of the mCare patient participants are enlisted service members; 16% are officers.  More than 90% of the volunteer users surveyed found the mCare application on their phone easy to use or somewhat easy to use.  Nearly 75% of the users surveyed preferred to receive contact through mCare more than once a week, and 65% reported that mCare improved their communications with their unit.

There have been a number of challenges to overcome to achieve success with the mCare project to date.  Because the goal was to leverage the patient’s personal cell phone, and not introduce a new technology to the Soldier, a wide variety of phone models and wireless carriers needed to be accommodated.  Each wireless carrier has separate testing and certification processes, and specific devices have different installation processes, which all result in a complex technological process to navigate for the clinical teams.  Developing  a streamlined process that was as simple as possible for the care team, while negotiating with each wireless carrier to allow the application to be accessible to patients at no cost has been  a time consuming process that is still ongoing.  Full integration with the patient health record (PHR) is not currently part of mCare’s model but the feasibility and cost to incorporate PHR is being explored. 

There is increasing interest in expanding the mCare to incorporate additional use cases and support other services outside the Army.  The Veterans Health Administration and the medical departments of the U.S. Navy and Air Force have shown interest in utilizing mCare to support their case management activities.  The Defense Veterans Brain Injury Center  would like to utilize mCare for patient follow up.  Additionally, other use cases such as medication monitoring, polypharmacy assessment, continuous positive airway pressure monitoring at home for sleep disorders, pain management and medical student well being evaluation have been proposed as additional use cases for mCare, with funding identified to enable this expansion. 

The second initiative I would like to highlight is Text4Baby.  Text4Baby (T4B) is a free mobile health information service that provides timely health information to women from early pregnancy through their babies’ first year.  Led by the National Healthy Mothers Healthy Babies Coalition, the T4B campaign has forged a new public-private partnership between government, private sector businesses, non-profits and academic institutions to develop innovative new models for leveraging mobile phones and the extensive cellular infrastructure to address critical healthcare challenges in the U.S. 

The T4B service aims to use one of the most widely used technologies in America—the mobile phone—to promote maternal and child health.  Women who sign up for the service receive three free text messages each week timed to their due date or baby’s date of birth.  The messages focus on topics critical to the health of mothers and babies, including nutrition, seasonal flu prevention and treatment, mental health issues, risks of tobacco use, oral health, immunization schedules, and safe sleep.   

The Army Medical Department plans to introduce T4B to military mothers at Madigan Army Medical Center at Joint Base Lewis McChord in Washington as part of a demonstration to formally evaluate the acceptability and utility of using text messaging to deliver information and encourage healthy behaviors as part of its overall maternal health outreach initiatives.

The third wireless application that the U.S. Army is investigating is the impact of a video cell phone reminder system on glycemic control in patients with diabetes mellitus (diabetes).  Diabetes affects approximately 24 million people in the U.S. and is associated with devastating complications in both personal and financial terms.  Diabetes is the leading cause of blindness, non-traumatic amputations, and renal failure in adults and reduces life expectancy by 5-10 years.  Maintaining glycemic control is critical for the health of diabetes patients.  The reasons why more patients do not reach appropriate goals for glycemic control are multiple and complex, among them poor compliance with self monitoring of blood glucose (SMBG) and medication non-adherence.  Despite the evidence showing the positive impact of SMBG, compliance with SMBG remains suboptimal. Approximately one-third of patients with diabetes are non-adherent to their medications—a compliance rate which is lower than many other medical conditions.

The hypothesis of this study being conducted at the Walter Reed Army Medical Center is that a cell phone video reminder system will improve self-care and glycemic control in patients with diabetes when compared with standard of care.  The primary endpoint is improvement of glycemic control as measured by A1C and the secondary endpoints are mean daily glucose levels, the number of both hypoglycemic and hyperglycemic events, the amount of time spent in target blood glucose, and the perceived level of diabetes-related stress between the two groups. 

Preliminary results show that A1C improves more in those patients who are provided with video reminders compared with those who did not receive them.  Overall, the viewership was about 50% which exceeds that of most other e-Health studies.  Among subjects who watched at least two-thirds of the daily, cell phone-based video tips/reminders the decline in A1C was greater than it was for subjects who used the technology less.  Using reminders delivered via the ubiquitous technology of cell phones appears to be an effective way to improve glycemic control and thereby long-term outcomes.  This approach could be modified for use in other chronic illnesses and in other unique populations such as the elderly and disabled. 

Currently, the U.S. Army Research and Development Command (RDECOM) is evaluating commercial handheld solutions such as iPad, iPhone, iPod, and other platforms and their applicability in a tactical setting.  RDECOM has developed numerous handheld command and control solutions and is supporting the development and transition of MilSpace, a combined planning and social networking environment. The Telemedicine and Advanced Technology Research Center is working with the RDECOM to leverage U.S. Army investments in mobile technology and apply it to health care both here in the U.S. as well as in deployed settings overseas.

The U.S. Army’s evolving role in humanitarian operations represents another opportunity to utilize mobile technology as it pertains to recently approved DoD policy on Medical Stability Operations.  The relative ubiquity of cell phones throughout the world makes them, potentially, a vital tool in creating medical infrastructure and sharing medical knowledge where they are most needed.

The opportunities presented by mHealth are considerable, yet there are several challenges to overcome.  It will be necessary to ensure that mobile applications are integrated with legacy information systems.  A wide variety of mobile devices will have to be supported, as well network connections of many types.  The security, privacy, and confidentiality of patient data both on the device and during its transmission remain important considerations.  Furthermore, regulatory issues may, ultimately, enter the picture.  As mobile phones evolve from simple communication tools into complex physiological data-gathering devices, the line between cell phone and medical device is blurring.  Finally, from a practical perspective, it is important to avoid overloading already-busy clinicians with more information than they are able to use. 

The U.S. Army Medical Department is committed to developing a strong research portfolio in mHealth.  The convergence of healthcare and mobile technologies has the potential to change the lives of individuals in rural and austere settings and contribute to improved care, healthier lifestyle choices, and ultimately, increased quality of life for service members as well as those in need throughout the world.  Thank you again for allowing me to highlight the Army Medical Department’s accomplishments and thank you for your continued support to those who serve our Nation.