How to Differentiate between mHealth technologies: The Four Elements of mHealth Technologies that Predict User Engagement

What keeps us engaged in mhealth technologies?

I had the pleasure of attending the Partners Connected Health Care Symposium in Boston, MA, on October 24-25, 2013 where forward-thinking health and technology professionals shared ideas in connected health care including innovators in the mhealth software industry such as, Philip Chen, Sam Patel, Eric Gombrich, Peter Costello,  John Moore, Ben Haywood, Peter Catford, and amazing academics, entrepreneurs, doctors and thought-leaders such as Dr. Joseph Kvedar, Amy Cueva, George Kassabgi, Peggy Johnson, and Dr. Joseph Cafazzo, just to name a very few!

My big take-away from the conference how to sort out which mobile health apps and software work and which don't and why.

It can be hard to how to differentiate between them.  But if we are going to use them, we need to know how to pick and choose.

Why mobile health matters.

But first let's review why mobile health matters so much.  With 90% of the world's population having access to a smartphone, 40,000 health apps currently available on the market and software companies creating new telehealth software every day, mobile is truly the world's largest technology platform and the world's largest health delivery opportunity.

David O'Reilly, CPO of Proteus Digital Health, hit the nail on the head when he said, during a panel discussion:

"The most powerful health care tool we have ever had is in everyone's pocket."

Mobile health matters because it is everywhere.  Smartphones are our favorite technology.  But it also matters because it works, providing improved patient outcomes at reduced cost.

But if you are a health or hospital administrator looking to invest in an mhealth technology, what should you look for?  How do you tell what is good and what is not so good?

George Kassabgi, entrepreneur and co-creator of Catch-Health spoke about what determines patient engagement in a mhealth product on Thursday afternoon.

"Dumb Ways to Die" Red Button

What doesn't work!

First I learned about what doesn't work.

Patients with a chronic health condition were given a telehealth device to use at home to help manage their condition.  If they pressed a button, the machine would automatically send critical health infomation to their doctor.  Simple, no?

Well these patients failed to comply with this device at an astonishingly high rate!

"What!" you are saying,  "What is easier than pressing a button?"  Why won't those patients, just press the button (echoes of Dumb Ways to Die in my head... hmm hmm hmm)!

But, as tempting as the button is to the morphoid on Dumb Ways to Die (for those of you without tweenish children, this was just recently a youtube hit sensation), a button doesn't really engage us humans, especially not after we learn what happens after pressing it the first time.  It's not warm, pretty, or exciting, and more than anything else, it does not engage us.  We tend to forget about it, and we definitely won't press it more than once.

What Works!

In essence, technology works if it is designed around the human brain, around what motivates us and makes us feel good.  George Kassagbi outlines the four features that predict user engagement in mhealth technologies. 

Tip #1:  George lays it out for us. First he says, the technology has to get us to work on a "team." We are, he pointed out, inherently social creatures, and are motivated to act when we know other people can see us, when we have an opportunity to mimic other people's behaviors, and when we know others are counting on us to be there.  Guess, what humans like being on teams!  I knew that!

So, let's say I am a woman recovering from depression and I log on to a service in which I can interact with a limited number of my peers, also struggling through recovery.  We all rely on each other for support and I am motivated to log on because I know we are working together as a team to be successful in recovery.  I want to see what they are doing, I want them to know what I have learned.  I interact because it is social and it draws me in with the opportunity to connect. 

Tip #2:  Secondly, he says, the technology has to help us form "tiny habits."  Instead of insisting on big changes or insisting on big behavior changes, the technology interface helps us learn new habits in small steps, reinforced by the social context.

Today, I see that my friend posts his favorite dark greens salad recipe and then lets me know that getting my daily intake of antioxidants is actually going to help my mood.  Because he suggests it and because I like salad anyway, I might just try his salad!  This is a small step for me, but combined with many other small health improvements, I am on the path to recovery from depression.   

Layers

Tip #3:  The third element he shared with us is the concept of, "unfolding layers,"  This really isn't as mysterious as it sounds.  Simply put, its about incentivizing and rewarding users for engagement.  Basically, he says, if a service provides ways for users to advance in levels, gain points, open new quests, earn badges, or even to compete with other users, it will be used repeatedly, providing greater benefit to the user.

We all want to achieve, in fact we are suckers for achievement!   I will gladly log on to record my daily self-care activities and medication compliance if I have the opportunity to earn points for doing so.  These points will move me into "Double Power Level," and I really want to be the first one on my team to get there!

Tip #4:  Lastly, George tells us, we need to make the technology platform positive and fun!  For me, this goes right along with the three he has already mentioned, but for George it's important enough to be mentioned separately!  I like it!

When my health coach posts an inspirational quote each day, I seek it out because it's positive and uplifting.  I engage with the service because I want something that makes me feel better.  I like her encouragement and her warmth, and I know I need it when I am feeling down.  And engaging more means that I get better over time.

The Good Ones Keep Us Coming Back

George tells us how to distinguish the good apples in mhealth from the not so good ones.  The good ones engage clients with intelligent design, so we keep coming back.  These technologies create a team for users, help to encourage small steps in health improvement, help to incentivize use through rewards and unfolding layers, and create a positive feeling for their users.

The bad ones offer utility without intelligent design.  They may offer a simple platform with information or one simple function, not tied to other people or allowing us opportunities to achieve.

Mental health app creators take heed, for these are the elements that distinguish the not-so-great mhealth tools from the stellar.

And for the rest of us, consumers, advocates, mental health clinicians, and administrators knowing what we now know helps us figure out which one to use.

Whether you are investing $2.99 for a mental health app for your own personal use, or whether you are investing $29,900 for a new telemental health platform, first ask yourself if these four elements are present, and whether you as a user would want to keep engaging with it.

If the technology will engage the client so they keep coming back again and again, the investment may be very much worth it.

Pics
Engaged:  http://www.flickr.com/photos/expressmonorail/2994523467/
Dumb Ways to Die Button  www.survivingcollege.com
Layers http://www.baptistmilestone.com

Text-Messaging: Real Service for Real People

October 11, 2010 was a day a therapist hopes she never will have.

For a therapist in San Francisco, this day started with the discovery of distressed text messages on her phone sent by one of her young clients, a teenager named Alex. He was desperate and thinking of ending his life.  He wanted to connect with her and needed her support.  But she didn't provide overnight text-messaging services.  The help he needed didn't reach him in time and he chose to end his life by suicide.

You can find more about this heartbreaking story at the website his family created, The Alex Project. 

Thankfully, San Francisco-based crisis text services have been created as a result of this tragedy to prevent further teen suicides.

In fact, text messaging services are popping up all over the country in response to our growing recognition as parents, advocates, mental health professionals, systems planners and funders, that in-person and phone-based services don't work for the majority of youth in crisis. 

In Minnesota, Nevada, and San Francisco, text services have been created and are doing phenomenal work to serve as a lifeline for youth who prefer to communicate via text messaging.  For a complete list of text-messaging services in the USA and abroad (luckily there are many) visit the unsuicide wiki, maintained by Canadian mental health advocate Sandra Kiume.   

A national service has also been formed.  Mental Health Advocate Nancy Lublin of DoSomething.org has worked tirelessly to create a new national service, the Crisis Text Line, which just launched in August 2013 and eventually will reach all youth in crisis in any part of the country.  This is a life-saving service that will be relied on by hundreds of thousands of young people every year.    

But, as Alex's situation poignantly illustrates, these anonymous texting services are not enough.  People want to connect with people they know and trust when they are in crisis.  Alex wanted to text his therapist but she did not provide mental health support via text-messaging.

In fact, many clients want to communicate with their therapists via text messaging and email.  Texting communications can be used for support as well as other general communications such as scheduling appointments. 

Clients want to text their therapists because its just how we communicate.  With 72% of adults and 95% of teens using their phones for text messaging every day, according to a Pew Internet study, it is becoming as ubiquitous as the telephone. 

And for many people, especially teens, who find verbal communication uncomfortable, texting offers a sense of safety, creating an environment that facilitates communication about sensitive subjects and difficult emotions. Thinking about how to reach teens by text-messaging to prevent suicide seems paramount.

The mental health profession is scrambling to catch up.  The majority of therapists and mental health centers do not offer text-messaging services.

But now is the time to move and adopt this service.  There are many software solutions already available and tried and tested to fill this gap.

Applications such as Hipaa Chat allow for two way text-messaging and video conferencing from an iPhone, with capacities for an Android system coming soon.  This application immediately destroys all information transmitted on it, so that no personal health information is stored on the phone where it can be harvested by applications and stored outside of a secure clinical record. 

But this is not the only software solution available.  Mosio, Educational Messaging Services, and iCarol also provide industry-standard encryption to provide secure text-messaging.  Each platform offers slightly different features.  Mosio combines email, chat and text messaging options together, EMS's Prevention Pays platform provides robust outgoing messaging as well as one-on-one texting, and iCarol offers chat and texting on one platform with substantial reporting capacities. 

And models for keeping these services sustainable and staffed also need to be explored.  A partnership with a local crisis center is the most cost effective and secure way to ensure your clients have 24/7 access to someone who can respond immediately and then communicate with the therapist if needed in an emergency.

Therapists can help their clients feel comfortable contacting the crisis center, explaining that they work together and the center can contact the anytime therapist if there truly is an emergency.  In this way the crisis center works effectively as an extension of the therapist-client relationship to facilitate help-seeking in a time of crisis. 

I encourage mental health professionals to start exploring these options actively and now!  People in crisis are trying to reach out for help every day via text messaging and we currently are unable to respond.

 

We are behind the curve, not meeting people where they are and this has resulted in lives lost.  Let's create real, responsive and accessible mental health services for all people. 

I know that text-messaging services can be a big part of that solution.

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How can technology help to better "engage" mental health clients?

In the realm of mental health care, do you know of a provider, organization or hospital that is talking about, their role in client engagement?  And what does this mean?

mHealth Summit in DC, December 2013

For me, engaging my client means motivating her to embrace her recovery by giving her multiple ways to engage with me and with her own treatment.  Basically, there should be as few barriers to help as possible, and as many opportunities to engage in treatment as possible. And, if her health does not improve, it's because I haven't engaged her enough by giving her options that work for her.

Unfortunately, holding mental health practitioners and the organizations they work for responsible for the mental health outcomes of their clients doesn't happen enough.  We usually provide one-dimensional care:  face-to-face counseling paired with optional medication management from a doctor.  Is this really enough?

This topic caught my eye when reading about the upcoming mHealth Summit in December:

mHealth's Role in Patient Engagement 

To comply with accountable care requirements and qualify for Meaningful Use incentive payments, providers must engage patients in their own health. Increasingly, hospitals, health systems and physician practices are tapping into mHealth solutions to achieve that goal. From mobile devices and apps to online portals and other emerging technologies, these powerful tools can connect patients with providers and their own personal health data to ensure high-quality, collaborative care before, during and after discharge.  And while some patients are highly motivated to track and manage their own health, reaching patients who need the most help can be tough.  

Tools to connect providers with their clients and clients with their own personal health data?  Does mental health need this?  If this is "patient engagement," yes, we need it!  

And what could these tools be?

•  Apps that help us track our daily moods and fluctuations, to show clients how they are improving over time (and to catch big downward spirals while they are happening).  
• An online personalized recovery toolkit, adapting the tools we already know and use in the mental health field including the Wellness Recovery Action Plan, Safety Planning, affirmations for positive change, cognitive coaching, goal-setting and any other tool we want to use, adapted to an online environment, handy at the fingertips of our clients.  
• A text message pushed out daily to our clients, asking how they are feeling on a scale of one to ten.  
• Positive messaging to our clients to provide encouragement and inspiration, or to remind them of their goals, on social media or text messaging. 

But these tools must not stop with an app in our client's pockets!  All these tools need to be connected to the team of family, friends and professionals supporting the client's recovery.  These tools must be used to enhance our relationship with our clients.

And evidence from text-based mental health programs is already teaching us that people say and do things differently in these spaces.  Disclosures of suicidality or past sexual abuse may happen first in the text-based environment.  And people who would not otherwise engage in treatment at all, reach out in online and text-based mediums.  These include teens and other people who feel stigma asking for help or have trouble communicating verbally.

It is critical that mental health adopts an assertive "patient engagement" stance to save lives and improve the lives of many more. One way to better engage our clients, especially those who are hard to engage, is to use mobile and online technologies to offer multiple channels of support in clinical care.

Join us to Discuss the Future of Mental Health Care at the AAS Conference, Austin, TX, Thursday, April 25th!

On Thursday, April 25th at 1: 30 p.m. I will be presenting, along with three of my favoite colleagues, Aaron Blackledge, TonyWood and April Foreman, at the Crisis Center Conference at the American Association of Suicidology's annual conference in Austin.  

The topic of our panel discussion will be, "Crisis Chat 10.0:  An Online Ecosystem for Mental Health Service Provision and Why It Makes Sense for Consumers and Providers."

We will be talking about the future of mental health care starting with the problems in our current system including the glaring fact that 50% of people that suffer from a mental health problem never get any help for their disorder (NIMH).  As mental health professionals and systems influencers, why are we not held accountable for this failure in access and treatment by the vulnerable population we serve?  

Aaron, Tony, April and I have envisioned a future model for mental health service provision that emanantes from a online services portal.   

We start with breaking down mental health care to it's basic concept that a caring connection with another human is what helps and heals.  If a connection is all it takes, then why make it so hard for people in need to connect to people who can help?  

Why put up barriers of time, place and person?  Why not make it easy for someone in crisis, or anyone at all in emotional pain, to reach out to someone who cares?

We will explain this comprehensive online mental health services portal, one that allows consumers of mental health services to access help where, how and when they want it, and one that can be funded by insurance companies, government and private pay, among other sources, because it provides better service AND it is cheaper than our current system!  The time is right!

We look forward to seeing you there!

Business Process Management for Non-Profit Organizations: The other side of IT.

Each process can be defined visually! 

Business Process Management (BPM) is a term borrowed from the for profit sphere to describe the definition of work processes within an organization, especially around technology systems.  If you have applied BPM techniques within your organization, you will find that your staff are working efficiently and productively, you will have data at your fingertips on program outcomes, and you will have no trouble complying with any standards you need to meet.  

BPM is the other side of IT.  Because all non profit organizations use technology, process management and technology are inseparable.  But, your IT consultants don't do this work for you. They are in the business of implementing software solutions and maintaining your technology infrastructure. Then they leave it to you to make that technology work for your organization.  

However, at the typical non profit organization the definition of process is usually not polished and there may be many areas where staff are not working efficiently.

Below are some of the common problems associated with unfinished process definition around technology.  If your organization can relate to a number of these issues, it may be time to put some time and energy into defining your processes around technology use.

Project Management:

• When working on editing a document together, we send it to each other on email, resulting in may versions in many places.
• Time spent on a contract by staff is done manually and handed into the project manager weekly for tallying.

Sheduling:

• It's hard to schedule meetings because we have no idea who is busy when and no way to figure it out except for emailing them or going to their office.
• Rooms are booked out using a paper calendar at the front office.

File Sharing:

• It’s hard to find documents that I need when I want them.
• Staff save documents wherever they like.
• We have documents in our drives from 10 years ago.

Client and Program Management:

• Our files are paper-based and it’s hard to pull data from them.
• All our files are electronic but they have repetitive data fields and staff find them difficult to fill out.
• I only have some of the program data that I need for reporting to stakeholders or the board.
• The data we have to report on our programs are simple client utilization numbers and not outcomes-based data that shows effectiveness of programs.

Inter-organizational communications:

• It’s hard for me to find important emails in my inbox.
• Staff are unaware of trainings and events in different programs.

But don’t despair, if any of these problems ring true for your organization, things can get better!  

Your "techie" and your best detail person are best matched to work together to define work processes within your organization. Your "detail" person is the person to whom details like policy and procedure, are important. This is typically not a clinician! Your “techie” is the person that just gets technology more than anyone else in the agency.  And sometimes your techie and your detail person are the same person, or two people with similar skills. If you don't have people with these skills internally, or you cannot divert staff from essential job functions, you will then need to pull in outside help.

Focusing on business process management will bring great gains to your organization.  Increased productivity for your staff, data at your fingertips on all aspects of your organization, and increased ability to integrate new programs and close down old ones are just some of the benefits.  

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Technology Optimization and Process Management for the Non-Profit

What is your vision for technology at your organization?

If your agency uses email, file sharing, electronic records, or a computer of any kind.... (everyone!) and you have invested time and resources into making sure you have the best systems available... (everyone!), then you also want assurance that they are working for your organization.  

You may be saying to yourself about now, "But don't be silly Jill we’ve got really great technology and IT support, so of course our systems are working for us!"

But do any of these very common non-profit technology glitches sound familiar?  
An electronic medical records system that requires staff to complete duplicative data fields?  

A file sharing system that is muddled up with files ten years old and so clumsy that no one can find what they need?  

Suddenly realizing that community contacts critical to the success of your organization have been lost because the person that had a file drawer full of business cards has left your organization?

These are problems that are the result of organizations not creating policy and defining workflow for their employees, especially around technology.  

The next question I commonly encounter here is, “But Jill, this is what we have IT staff do for us.”

And yes, these are the tasks that you hoped and banked on your IT consultants doing for you only to find out that they don’t do these things.  They are there to implement and maintain the systems you choose for your organization, but are not experts on defining workflow around these systems.  

And finally, you may be saying, “Ok, if it’s never been done and my staff and I can’t take time away from direct service provision to do it, how do we fix it?”

Unless you have staff dedicated to internal definition of workflow and policy, this stuff just has never been done!

BUT YOU ARE NOT ALONE!  None of us non profit managers or health professionals were formally trained in our course of study with any of this “process”  and "computer stuff".

But don't panic here are five easy steps that will get you well on your way to having a plan that is as good as the best organizations in our field.

1.  First, what are your most critical organizational outcomes?

Think macro here, think what makes your organization tick, and what at the end of the day you need to do above all else to ensure the sustainability of your organization.

Some examples are:  provision of excellent clinical care, diversion of patients from emergency rooms, connecting clients to employment, a reputation for excellent service in the community, or fundraising.

2.  Next draw a line from each one of those outcome statements to a list of data that stem from these critical organizational outcomes.    

For example, if we use the “provision of excellent clinical care” as our outcome, the data linked to this may include measures of client satisfaction or positive resolution of treatment goals.

3.  Next figure out what internal processes occur to ensure these outcomes and data points are met.  To make it simple just draw another line underneath the data points, connecting the group to these processes.

For example, under “excellent clinical care” we would list clinical supervision, staff communication, intake procedures, quality assurance and utilization review as processes that have to occur smoothly to ensure that excellent client care is met.

4.  And finally, draw another line below the processes to connect it with the technology platforms that facilitate this data collection and internal processes.

Common technology platforms at a non-profit include an email, calendaring and file sharing system, a telephone system, an electronic medical records and billing system, a donor management system and a customer relationship management system.

5.  Lastly, describe how your current platforms support the data collection and internal processes or don’t support them!  Some free-flow creative thinking at this point is most helpful.

And once we’ve done this work (phew!) the strengths and holes in your technology processes become more visible. You will see more clearly where workflow needs to be redesigned or defined. You will also begin to understand which organizational processes are poorly supported by technology, or where existing technology is not being used to it's fullest extent.

Best of luck as you embark on your journey.  

For more information on Technology Optimization and Process Management at a Non-Profit, or to learn how you can get assistance with technology assessments and planning, visit http://www.jatasource.com

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Making Mental Health Care Accessible and Responsive: a call to action.

At my agency, Family and Children's Service of the Capital Region, we are currently re-designing our services to provide more accessibility for our EAP and other clinical counseling clients.  

Only 36% of people living with a mental health disorder receive treatment for that disorder (National Institute of Mental Health). We know that this statistic rings true for our local region and our EAP members as well. In general, people suffering from a mental health disorder do not reach out for help, or they wait until it gets really bad to reach out.  

So, how does an agency try to bend this trend and increase the utilization of mental health services, truly serving more people in need?

At our agency, phasing it in this year, we will start to try to "bend this trend," by providing telephone, chat and email service.  This service will be more immediate and easier to access. Clients will no longer access service by calling us and and then waiting for a scheduled face-to-face appointment a week later.  Calls will be answered by counselors and they will be provided service immediately if they need it. 

If they want to call us about their issue and receive support on the phone for 20 min, they will get it.  If they want to chat to us from work on their lunch break about the anxiety they are having at work, they will be able to do it.  If they want to email us to simply ask for resources on parenting, they can do that too.  In all cases we will provide them with the service they ask for, however they choose to ask for it, and when they want it.   We will be tracking our utilization and hope to see it go up drastically, as we know that by using the old school in-person counseling model exclusively, we are missing the majority of the people that need help.

The consumer of today needs and in fact demands much more.  Everything else we consume is offered how and where we want it.  Pizza at our doorsteps, groceries and clothes in one big box store, books and movies on-demand online.  The mental health consumer of today wants service in the same way.

It's up to us, mental health administrators and managers, to figure out how to provide high quality, clinically appropriate care in multiple ways. Waiting and insisting that clients come to us for care is not only unrealistic, but irresponsible. Face-to-face counseling will always be needed and in fact, is preferable, but we need to figure out better ways to engage MORE people, to engage them at lower level, less intense service levels as well. Otherwise, we will continue to miss the 64% of people that live with a mental health disorder every year but never access care.

Let’s start thinking bravely and figure out what makes mental health care accessible and responsive.  Next, let’s not get hung up on, “but I don’t know how to do that (ie social media, online, apps, texting, email service),” and instead find someone who does know how to do it (there are many of them) or take an online course at the TeleMentalHealth Institute to educate yourself on how to make the needed adjustments.

Not only will you be better fulfilling your mission to serve, but in the end, you will have more business and better business. 

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