mHealth in Chronic Disease Management: Case Study of a Mobile-to-Mobile Delivery Model Thornbury, W.C., MD1, Thornbury, S.C., MBA2 meVisit Technologies, Glasgow, KY USA, [email protected] 2 meVisit Technologies, Las Vegas, NV USA, [email protected] 1

Abstract: The United States health system in its current architecture is unsustainable. New care models that capably address chronic disease, 75% of the health dollar, are imperative. A 24-month pilot study investigated a novel mobile-to-mobile e-visit application in the care of established patients in a primary care practice from January 2011 to December 2012. Care was provided within the patient-centered medical home model for minor and some moderate acute illness, as well as, chronic disease care in the second year. After 471 consecutive cases, clinic productivity increased 15% and per-capita costs declined 15%. The results suggest that a mobile-to-mobile delivery model provides a new generation of telehealth that can be effectively translated into the medical home. Mobility increased quality of experience for patient, provider, and practice--all the while, safely rendering cost-effective access to care to the United States largest driver of health costs, chronic disease. Introduction The United States health system in both its organization and delivery is unsustainable in the current architecture"[1]. It is simply too costly to continue in its present manifestation [2]. One major cost driver is the disposition and delivery of chronic disease care. Patients engage the health system for both acute and chronic disease care via primary care medicine. Starfield, et.al, documented that within primary care, an established medical home relationship provided the best outcomes and lowest cost of care [3,4]. However, traditionally, telehealth has not generally been practical within the medical home, as it was designed to engage geographically isolated patients with medical specialists in a manner that attempted to recreate the office-based encounter. Current commercial

technologies have built upon the non-medical home structure to provide care of minor acute illness; however, such a delivery model provides limits for the effective disposition of chronic disease care, as brick-and-mortar follow-up is not possible for complications and ongoing care. In an effort to address the need for efficient and cost-restrained access to medical care, a mobile-to-mobile telehealth delivery model may offer some unique advantages. If conducted in a manner that could engage primary care medical providers, it would make the medical home relationship amenable to the model; and, if proven safe, might address the care of stable chronic disease care. Methods Study Design As the mobile-to-mobile model represented a unique delivery method at the initiation of the study, the first year was devoted to the treatment of minor acute care in an effort to evaluate safety and reliable clinical care. The second year addressed some moderate acute care, as well as, designating 20% of cases for the care of stable chronic disease. Chronic diseases addressed included minor changes in the management of diabetes, hypertension, thyroid disorders, minor cognitive diseases, gout, and dyslipidemia. Sample Selection We used a convenient sample selected by the physician that represented about 25% of the regularly active patients in the medical practice. The physician was a primary care physician located in rural, South Central Kentucky, U.S.A. Care was provided from January 6, 2011-December 31, 2012, representing two years of continuous clinical care. Architecture of the Delivery Model Established patients of the practice were placed in cohort with their medical home physician. They completed a cursory past medical history online that included demographics, medical allergies, ongoing problems/care, current medications and significant surgical history. Twentyfour hour access was provided from either a mobile device or computer; and, a visit was initiated after a HIPAA-secure login and review for any change in medical history. The patient was directed to complete an online, logic-based interrogation engine. They were provided an option to add unstructured comments and up to five photographs. The history was formatted into a traditional HPI, and

then added to the stored past medical history and submitted to the physician. The physician reviewed the case, completed assessment/plan, and submitted a prescription, if appropriate, to the pharmacy from a mobile device. A unilateral option to contact the patient by phone or video was possible. A care plan with encounter-specific education was returned to patient and medical record. Average provider turnaround was less than four minutes. Results The practice completed 471 mobile online encounters over the 24-month period with no reported safety events or adverse outcomes. Encounters increased 53% from year 1 (188) to year 2 (283). The mean patient age was 41 years with a variance from 16-90 years old. Most online encounters were conducted by women 1.7:1, with 95% (447) occurring before 10:00PM, and 81% (382) after clinic hours of operation. The average encounter time was less than four minutes for each encounter. Patients were served in twelve Kentucky counties with an estimated sphere of influence of 4,300sq mi. Five of the counties are designated by the United States government as rural, Appalachian, and thus, special needs. Care was also delivered to patients in four states outside of Kentucky that included: California, Florida, Alabama, and Tennessee. In the study’s second year, 20% of cases (57/283) were designated chronic disease care. There was an increase in the clinic’s productivity of 14.92% from baseline defined as the increase in capacity of the practice to deliver care. Also, there was a reduction in per-capita cost of care of 14.93% ($191.76/$225.42) based on federal tax return filings of annualized expenses of the practice per active patient base. Discussion A literature search conducted before the initiation of the study did not reveal any prior art in a mobile-to-mobile delivery model of clinical medical care. Therefore, it was necessary to both engineer and develop a web-based software architecture to provide this degree or freedom for patient and physician. The fiscal development was accounted for using a separate corporate structure. To overview the study and provide counsel, we enjoined a regional academic partner, the University of Kentucky; and, a dialogue continues presently as we evaluate the ongoing experience of the delivery model. There were two important nuances that were integral to the success of the delivery model. The first, and most influential, being the ability to drive the

physician’s response time to less than four minutes per encounter—the functional limit to what we believe will engage a provider to maintain care both during and after clinic hours of operation. In effect, this alone, allowed telehealth to become practical within the medical home relationship between a physician and their established patient. The second being that the engineering allowed the physician the freedom to dispose of each encounter as they deemed appropriate—be it an asynchronous e-Visit, and e-Visit augmented with telephone communication, or a face-to-face video encounter. An increased clinical efficiency, and flexibility in the disposition of care, allowed the primary care physician to remain engaged; and, ergo, maintain the medical home patient relationship. It is this established relationship that permitted the mobile delivery model to address more complex care than present generation telehealth models. Well-established clinical relationships are particularly important in the care rendered for chronic diseases. In stable chronic disease, the physician is commonly used as an analyst, educator, and motivator; the diagnosis is not in question and fine-tuning of an established regimen is, generally, the requirement. Mobility simply allows such care to proceed in a more cost-effective and effective manner for the health system. In summary, this case study demonstrates the safe clinical care for some stable chronic diseases using a novel mobile-to-mobile delivery model. The mobile construction for both the physician and the patient represents a new generation of online telehealth---one available to primary care and specialty providers, alike. Mobility allowed the medical providers and patients to retain access to care maintaining their established clinical relationship. The delivery model fulfilled the conscience of the Triple Aim by providing care to more patients, using fewer resources, under an umbrella of increased access. Moving forward, new and efficient delivery models such as those demonstrated by this case study, will be a necessity for the United States health system to make the care for chronic disease both available and affordable. References [1]

[2] [3]

Reid, P.P., Compton, W.C., Grossman, J.H., et al. “Building a Better Delivery System: A New Engineering Healthcare Partnership.” National Academy of Engineering and Institute of Medicine Committee on Engineering and the Healthcare System; Washington (DC). National Academies Press, 2005 Institute of Medicine. “Best care at lower cost: The path to continuously learning healthcare in America,” IOM Consensus Report, Sept. 6, 2012 Starfield B., Leiyu S., Macinko J. “Contribution of primary care to health systems and health,” Milbank Quarterly, Vol. 83: 3, pp. 457-502, 2005

[4]

Starfield B., Lemke K.W., Bernhardt, T. et al. “Comorbidity: Implications for the importance of primary care in case' management,”. Ann. Fam. Med, vol. 1:1, pp. 8-14, 2003

Authors’ Info William Thornbury, Jr. has a B.S. Pharmacy degree from the University of Kentucky (1985) and matriculated summa cum laude from the University of Louisville School of Medicine (1995). He served as resident two years in General Surgery (1997) at the University of Louisville-affiliated hospital system, and completed his residency in Family Medicine as chief resident at T.J. Samson Regional Health (1999). He has trained in Lean Systems under Toyota’s direct supervision at the University of Kentucky College of Engineering (2010). Dr. Thornbury is the CEO of Medical Associates Clinic in Glasgow, Kentucky and has worked in mHealth as Founder of meVisit Technologies since 2011. Steven Thornbury has a B.S. Pharmacy Degree from the University of Kentucky (1986). He has a background in pharmaceutical, medical device, and stem cell work in sales, marketing, business development and pre-clinical as well as clinical research internationally (1994 - 2009). He has been working in mHealth as a researcher and business development executive since earning his M.B.A from the Gatton College of Business and Economics at the University of Kentucky (2011).