@Article{info:doi/10.2196/iproc.8586, author="Kooij, Laura and Groen, G. Wim and van Harten, H. Wim", title="Barriers and Facilitators to Patient Portal Implementation From an Organizational Perspective: Qualitative Study", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e52", keywords="implementation", keywords="Patient portals", keywords="Health Information Technology", abstract="Background: Patient-centeredness is an important element of high-quality care. Patient portals can contribute to the patient-centered care and are defined as ``an online gateway for patients to gather and share information mostly provided by one health institution.'' While portals can have positive effects, its implementation has a major impact on the healthcare institutions providing those. Little is known about the organizational factors that facilitate or hinder successful implementation. Knowledge of the specific barriers and facilitators of different stakeholders may be useful for future implementations. Objective: The objective of this study is to identify the barriers and facilitators of patient portal implementation among different stakeholders within the hospital organization. Methods: Purposive sampling was used to select hospitals of different classes. Two university medical centers (UMCs), 3 mid-size hospitals and 2 general hospitals were included. Per hospital three stakeholders were interviewed including: 1) medical professionals, 2) managers, and 3) IT employees. Semi-structured interviews were conducted using the comprehensive model of Grol and Wensing, which describes barriers and facilitators of change in healthcare practice. Barriers and facilitators can occur on six levels: 1) Innovation, 2) Individual professional, 3) Patient, 4) Social Context, 5) Organizational Context, 6) Economic Context. Two researchers independently selected and coded quotes by using this model. Additional factors related to technical and portal characteristics were added by using the model of McGinn et al developed for implementation of electronic medical records Results: In total, we identified 382 quotes in 34 categories. Twenty-five categories were common for all stakeholders groups, including 16 barriers and 13 facilitators. Positive aspects related to `advantage in practice' were mentioned most frequently, followed by positive `attitude' and `motivation to change'. The main barriers were `resources' (eg lack of staff), `opinion of colleagues' (eg, negative beliefs) and `privacy and security' (eg, strict regulations). Similarities and differences were found between stakeholder groups and hospital classes. For example, medical professionals and IT employees considered 'resources' as an essential barrier. However, their perspectives differed regarding 'opinion of colleagues' as this was a major barrier for medical professionals (eg doctors with negative attitudes), but a facilitator for IT employees (eg, portal implementation can drive a positive change). Results of mid-size and general hospitals were largely comparable, whereas differences were identified for the UMCs. Conclusions: The model of Grol and Wensing proved to be useful in elicitation and classification of barriers and facilitators to portal implementation. However, technical and aspects related to portal characteristics (such as 'privacy and security' and 'perceived ease of use') were missing, and were added from the McGinn model. Barriers and facilitators occurred at various levels and differed between hospital classes and stakeholder groups on several aspects (eg 'opinion of colleagues' and 'cost issues'). This underscores the added value of involving multiple stakeholders in future portal implementations. The identified set of barriers and facilitators may be useful to make strategic and efficient implementation plans. ", doi="10.2196/iproc.8586", url="http://www.iproc.org/2017/1/e52/" } @Article{info:doi/10.2196/iproc.8700, author="Petrakis, Ann Beth and Reilly, D. Erin and Wiener, S. Renda and Pigeon, R. Wilfred and Kuhn, Eric and McInnes, Keith D. and Owen, E. Jason and Quigley, S. Karen", title="Simple to Use: Reflections From a Mobile Sleep Study Pilot", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e53", keywords="usability testing", keywords="Veterans health", keywords="sleep", abstract="Background: Difficulty falling asleep and staying asleep are common problems that affect over 30 million Americans. Additionally, we know that military personnel and Veterans often have insomnia problems post deployment. Home sleep monitors can be used to diagnose sleep disorders and determine if the sleep issue cause is a physical issue, such as obstructive sleep apnea. Some non-physiological causes may be improved by focusing on behavioral change, which can be assisted by mobile health (mHealth) technologies. In addition, mHealth apps are an increasingly popular method to deliver behavioral change interventions for a variety of conditions, with the cognitive behavioral therapy for Insomnia Coach app (CBT-i Coach) being particularly popular (it has been downloaded over 80,000 times in 86 countries). Objective: In this pilot trial we assessed the usability and feasibility of mobile health information technologies (HITs) designed to reduce sleep problems in post-9/11 Veterans with chronic insomnia. We used the CBT-i Coach mobile app (based on cognitive behavioral therapy for insomnia) and supplemented it with usage instructions to enhance self-management. Participants also used a home-based sleep monitor (WatchPAT) to obtain objective sleep data to assess possible sleep apnea and to provide subjects with objective data to motivate behavioral change. Methods: Thirty-eight post-9/11 Veterans met criteria for insomnia on the Insomnia Severity Index (ISI). We assessed feasibility and usability of the HITs over a 6-week intervention with a pre-post design. The WatchPAT was used to screen for sleep apnea, and those with moderate to severe apnea were withdrawn from the trial and referred for further assessment. Participants were given a self-management guide which detailed when to use different elements of the CBT-i Coach app, including guidance to complete a sleep diary each morning. Assessments were completed at the beginning, middle, and end of the 6-week intervention. Results: Of the 38 enrolled, 18 participants were withdrawn for moderate or severe sleep apnea as measured by the WatchPAT, and 9 withdrew for personal reasons. Post-intervention qualitative interviews revealed that many participants found both the CBT-i Coach app and WatchPAT easy to use. Participants also liked tracking their daily sleep and seeing graphical results of their sleep changes over time, with only 2 of the final 11 participants completing CBT-I Coach sleep diaries less than 85\% of the time. Exploratory analyses on the 11 completers also revealed significant but modest differences between baseline ISI scores (M=16.63, SD = 5.55) and post-intervention follow-up (M=12.82, SD = 3.74; t (10) = 4.14, P<.01). Conclusions: We found good usability of the combined CBT-i Coach app and WatchPAT sleep intervention and determined that feasibility was reasonable, with more than half of those not excluded due to apnea completing all assessments. The pilot demonstrated reasonable feasibility and usability of the mobile HIT tools which could provide an accessible adjunct or alternative to in-person cognitive behavioral therapy for insomnia to improve the health and wellbeing of busy individuals. ", doi="10.2196/iproc.8700", url="http://www.iproc.org/2017/1/e53/" } @Article{info:doi/10.2196/iproc.8698, author="Wissig, Stephanie and Hunn, Julianne and Zheng, Hua and Lemay, Celeste and Ayers, David and Franklin, Patricia", title="The Benefits of Direct-to-Patient Data Collection for Data Consistency and Completeness: Lessons From Force-Tjr", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e54", keywords="patient-reported outcomes", keywords="Registries", keywords="routine outcome monitoring", keywords="orthopedics", abstract="Background: In 2011, the Department of Orthopedics and Rehabilitation at UMass Medical School was awarded an AHRQ grant to establish a national registry of comprehensive total joint replacement (TJR) outcomes registry, FORCE-TJR. This lead to the development of an infrastructure for successful longitudinal direct-to-patient data capture, which has now been translated into a product to support orthopedic outcomes measurement in hospitals and surgeon practices around the country. Objective: To use data from the FORCE-TJR registry to demonstrate the benefits of direct-to-patient data capture for data consistency and completeness. Methods: To be a comprehensive TJR outcomes registry, FORCE-TJR required the development of a data capture system that supported complete and consistent research quality data. For this work, we first explored how our data capture system differs from other commercial and research based outcomes measurement systems. We then queried our integrated database of patient-reported outcomes, risk factors, adverse events, and claims to demonstrate how these differences affect data consistency and completeness. Results: We found that direct-to-patient data capture led to more complete measurement of adverse events as 25\% of post-TJR ER visits, hospital readmission, and early revisions occurred outside of the surgical hospital. Direct-to-patient data capture increased the capture of key risk factors, such as morbid obesity, eight-fold as compared to claims data. Finally, when compared to ``in-office'' outcomes measurement, web-based, direct-to-patient methods increased data completion rates from 53\% to 86\%. Conclusions: Web-based, direct-to-patient outcomes data collection improves data consistency and completeness as compared to other data capture methods supporting the collection of research quality data. ", doi="10.2196/iproc.8698", url="http://www.iproc.org/2017/1/e54/" } @Article{info:doi/10.2196/iproc.8504, author="Pratap, Abhishek and Anguera, A. Joaquin and Renn, N. Brenna and Volponi, Joshua and Atkins, C. David and Mooney, D. Sean and Are{\'a}n, A. Pat", title="Assessing Depression in the Wild: Insights From Two Large-Scale Fully Mobile Randomized Clinical Trials", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e46", keywords="Depression", keywords="Hispanic/Latino", keywords="minority group", keywords="Mobile health (mHealth)", keywords="mobile health intervention", keywords="sensors", keywords="smartphone", abstract="Background: The dispassionate ability of smartphones to stream real-time, personalized data from an array of onboard sensors can inform assessment and treatment of a range of medical conditions, including mental health issues. This technology can potentially address some of the known access barriers, including cost, time, stigma, shortage of mental health professionals, language barriers and other factors that prevent people from seeking help in a timely fashion. While this technology holds much promise in healthcare, its utility in describing patient phenotype from passive sensor data is unclear and an important area for research. Objective: We will summarize the key learnings from two large-scale (>2,000 enrolled people) fully mobile clinical trials targeting depressed individuals. Both studies were designed to assess the feasibility of running a remote, randomized controlled trial via custom applications. While BRIGHTEN v1 was open to the general US population, BRIGHTEN v2 was designed to enroll both English-speaking and an underserved Latino/Hispanic population. Here we will highlight the noticeable differences in user recruitment, engagement, and daily mood prediction observed across these studies, and explore the possible differences for each. Methods: Both studies recruited participants through ads on Craigslist, targeted social media campaigns and other online classified-like resources. In total, 7,433 people responded and were screened for eligibility. Adults (18 years and older) with mild to severe depression as determined by a Patient Health Questionnaire [PHQ-9] score ?5 were eligible to join the study. There were 3,310 eligible participants, of which 2,176 were enrolled. Sensor-based data were collected passively, from typical smartphone usage (aggregated call logs and messaging history for people with Android-based phones, and GPS data for both iOS and Android devices). The main outcomes of the study were depressive symptomatology, quantified by the PHQ-9. Daily mood fluctuations were measured using a two-item depression questionnaire (PHQ-2). Results: The overall compliance (the number of unique days an individual participates---i.e. completes active tasks) was drastically lower for V2 study with <40\% users completing any active task during the week 1 compared to {\textasciitilde}80\% in the V1 study. Considerable heterogeneity was seen amongst individuals when comparing the association of self-reported mood (PHQ-2/9 score) to various passive features, limiting the generation of a generalized cohort-level model for predicting mood (PHQ-2/9 score) based on passive features. Personalized models predicting mood at an individual level revealed a signal for some individuals (median R2 {\textasciitilde} 0.25). However, predictive power in the V1 study using individual digital behavior for four weeks was modest at best (median R2 {\textasciitilde} 0.15). Conclusions: These studies demonstrate the feasibility of conducting large-scale mobile-based randomized trials and a marginal signal in the passive data to predict daily mood. However, further research is warranted to assess clinical relevance. Compliance was the primary factor affecting data analysis, and it limited our ability to draw inferences or employ predictive modeling at the cohort level. Studies are required to understand barriers and facilitators that are required to engage people, especially those with mental health issues. ", doi="10.2196/iproc.8504", url="http://www.iproc.org/2017/1/e46/" } @Article{info:doi/10.2196/iproc.8709, author="Mohan, Girish and Mechanic, Oren and Stavert, Robert", title="Utilizing a Teledermatology Service to Impact Knowledge Acquisition Among Primary Care Providers", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e40", keywords="teleconsultation", keywords="telehealth", keywords="telemedicine", abstract="Background: A majority of patients seeking care for skin-related complaints are evaluated by non-dermatologists---in particular, primary care physicians. However, a majority of primary care physicians do not feel confident in their ability to diagnose and manage dermatologic disease, and rates of diagnostic error are high. It has been suggested that a teledermatology service has the potential to improve the dermatologic education of internists. However, this has not to date been rigorously evaluated. Objective: Teledermatology is the use of telecommunications tools to transfer dermatologic information. The most common modality is ``store and forward'' (SAF). This project proposes to evaluate the impact of a new SAF teledermatology system on a group of referring primary care providers at the Cambridge Health Alliance, in terms of dermatologic knowledge as well as subjective comfort with managing dermatologic conditions. Methods: Recently, access to a teledermatology platform integrated within an electronic medical record system, was rolled out for the first time to several primary care clinics in the Cambridge Health Alliance network. Primary care providers were asked to complete a short survey which consisted of fifteen ``Medical Knowledge Self Assessment Program'' questions from the dermatology portion of an internal medicine board review course. The providers were also asked to answer subjective questions regarding perceptions about their patients' access to dermatologic care, and their relative confidence and ability to diagnose, manage, and treat different dermatologic conditions. Providers were asked to give their names so that they could be contacted in 12 months, at which time the same survey could be given again to evaluate changes in knowledge and perceptions. Results: A total of 19 primary care providers completed the requested questions and surveys; 17 providers from the initial pool of 19 completed follow-up questions and surveys. The average score on the test of dermatologic knowledge among the participating providers increased from 11 to 11.8 out of a possible 15 questions (P=.07). Providers who performed fewer than the mean number of consultations (11 or fewer) had minimal improvement in their overall test scores, while providers who completed 12 or more teledermatology consultations during the study period demonstrated a greater improvement in their test scores. Providers also reported improvement in their perceptions of diagnosing and treating dermatologic problems. Conclusions: Our findings demonstrate a trend towards improved knowledge acquisition among providers using the platform, correlated with the frequency with which they use the platform. In addition, subjective survey responses by referring providers indicated a trend towards improved self-assessed confidence in managing different dermatologic conditions for their patients, as well as decreased barriers to dermatologic care for their patients. Although further studies with larger sample sizes are needed, our findings indicate that telemedicine consultation can potentially be utilized to improve referring provider knowledge and confidence. ", doi="10.2196/iproc.8709", url="http://www.iproc.org/2017/1/e40/" } @Article{info:doi/10.2196/iproc.8601, author="Wang, Jing and Branson, Sandra and Boss, Lisa", title="Attitudes Toward Aging in Place Using Wearable and Remote Monitoring Technology Among Underserved Homebound Seniors", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e39", keywords="aging in place", keywords="homebound", keywords="wearable", keywords="remote monitoring", abstract="Background: Wearable and remote monitoring technology have great potential to support homebound seniors aging in place. However, the seniors' adoption of new technology has been slow, and current research has focused primarily on the rich and the motivated. Objective: The purpose of this study was to investigate underserved homebound seniors' attitudes, including their current use, interests, preferences, and potential concerns toward aging in place using wearable and remote monitoring technology. Methods: A cross sectional survey study was conducted with 181 seniors who were participants of the Meals on Wheels program. In order to be eligible for this program, clients must be disabled adults who are homebound and over 60 years of age. Results: The sample had an average age of 77 years. The group of participants was 66\% female, 36\% African American, and 49\% White. Nearly 51\% of the residents sampled in this study reported that they lived alone; 22.7\% lived with a spouse; and 22.7\% lived with family. More than half the sample (54.7\%) reported having ever used a health-monitoring device at home, such as a blood pressure monitor or a blood glucose meter. More than half of the resident had access to electronic devices such as a television (92.8\%), regular cell phone (58.0\%), DVD player (56.9\%), or a landline telephone (53.6\%). A smaller percentage had more popular electronic devices, such as a smartphone (21.0\%), laptop computer (18.8\%), desktop computer (12.7\%), or tablet (12.2\%). Only 1\% of the residents sampled reported having no access to any type of electronic device. Nearly 50\% of the residents surveyed had never heard of wearable health devices; most had never used such devices (84.0\%). Sixty-one percent of the residents reported that they would be interested in using a wearable device. Well over half of the residents (68.5\%) would prefer to wear the device on their wrist. This sample reported an interest in tracking the following with wearable devices: blood pressure (51.4\%), heart rate (44.8\%), exercise and physical activity (35.4\%), blood sugar (34.3\%), fall risk (32.6\%), hours and quality of sleep (32.6\%), weight 27.6\%, diet (27.1\%), body posture (19.3\%), mood (17.7\%), and other (9.9\%). When asked about what concerns residents had about using wearable devices, 55.2\% reported cost to be a concern. Other concerns were related to safety (20.4\%), privacy (16.0\%), fraud (14.4\%), and overwhelming information (11.0\%). Twenty-five percent of the residents reported having no concerns. Conclusions: While the majority of the underserved homebound seniors had never used any wearable or remote monitoring technology to support aging in place, and half had never heard of them, there is a great amount of interest in using such technology in this underserved population. Cost is the primary barrier to their adoption. Additional studies are needed to examine cost-effectiveness of using such technology to prevent expensive emergency room and other health services due to poor management of chronic conditions in this underserved population. ", doi="10.2196/iproc.8601", url="http://www.iproc.org/2017/1/e39/" } @Article{info:doi/10.2196/iproc.8579, author="Reginatto, Brenda and Donnelly, Susie and Kearns, Oisin and McCarthy, Marie and Byrom, Bill and Greene, Barry and Goheen, Dre and Caulfield, Brian", title="The Burden of a Remote Trial in a Care Home Setting: Qualitative Study", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e35", keywords="mobile technology", keywords="older adults", keywords="remote trial", keywords="burden", keywords="wearable technology", keywords="participant experience", abstract="Background: Older adults, particularly those with physical and cognitive impairments, are typically under-recruited in clinical trials, despite the fact that they experience the greatest need for healthcare services. Reasons for underrepresentation are disparate but may relate to comorbidities, communication difficulties (e.g. hearing and vision impairments) and physical immobility that constrains transportation to a research site. Remote trials supported by mobile and wearable health technologies have the potential to make clinical research participation more accessible for these groups. In order to determine the feasibility of this model, it is essential to understand the burden remote data collection places on the participants involved. Objective: The REACHES study (Remote Assessment of Older People in a Care Home Setting) explored the burden experienced by participants in a remote trial supported by mobile and wearable technology in a care home setting. Methods: The remote trial focused on implementing a falls prevention programme in a single care home over an eight-week period from March to May 2017. The following technological solutions were selected to support the activities of the trial: QTUG{\texttrademark} (Kinesis Health Technologies, Ireland), a sensor-based medical device that assesses gait, mobility, falls risk and frailty; Aging Research App (ICON Clinical Research, Ireland in partnership with mPROVE Health, US), a tablet version of the Age-Related Muscle Loss Questionnaire that assesses the impact of muscle loss on activities of daily living; and v{\'i}vosmart? HR (Garmin Ltd., US) a wrist-worn device that tracks daily activity, heart rate and sleep patterns. These devices provided outcome measures for falls risk and mobility in older adults; offer a variety of data collection methods; and are conducive to remote data collection. A participatory design was used to define the study procedures from the outset. A range of qualitative methods were used to capture the ``lived experience'' of staff and residents participating in the trial. These included semi-structured interviews, ethnographic observations and diaries. Qualitative analytical procedures were employed using thematic analysis supported by NVivo software (QSR International). Results: A total of 6 residents and 8 members of staff participated in the semi-structured interviews (n=14). Results showed that staff experienced extensive burden in fulfilling their roles and responsibilities to support the remote trial, whereas residents reported limited burden. For both groups, the burden of comprehending the research and associated tasks was prominent. Additionally, for staff a lack of time emerged as a substantial burden. Findings suggest that the experience of burden was not mitigated by the perceived value of the trial. Conclusions: These findings provide insight into the experience of burden of a remote clinical trial among staff and residents in a care home setting. Understanding and mitigating the burden created by remote trials is vital to researchers and companies attempting to scale such a model. Future research could build on the lessons learned from the REACHES study to develop a method to measure the burden remote clinical trial protocols place on patients and other stakeholders involved. ", doi="10.2196/iproc.8579", url="http://www.iproc.org/2017/1/e35/" } @Article{info:doi/10.2196/iproc.8459, author="Pinney, Sean and Otobo, Emamuzo and Freeman, Robert and Rogers, Jason and Fasihuddin, Farah and Ramireddy, Karthik and Deorocki, Allyssa and Hassanzadeh, Neda and Goldstein, Marni and Zlatopolsky, Rivelle and Ullman, Jennifer and Atreja, Ashish", title="Use of Electronic Patient Reported Outcomes and Automated Devices for Heart Failure Disease Management", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e24", keywords="congestive heart failure", keywords="sensors", keywords="quality of life", keywords="electronic patient reported outcomes", keywords="remote monitoring", keywords="self-management", keywords="hospital readmission", abstract="Background: Congestive heart failure (CHF) is a major public health issue. Today, CHF affects 6.5 million people in the U.S. and the incidence rate is projected to rise by 46\% to more than 8 million cases by 2030. Current reimbursement policies use readmission rates and length of hospital stays as indicators of quality of care, and incentivize providers to meet these quality measures as the cost of hospitalization alone significantly contributes to the overall burden of CHF on patients and health systems. Symptoms of CHF can be unpredictable and presently there are no reliable solutions to track disease control for discharged patients. Objective: This study aims to improve patients' self-monitoring practices post-hospital discharge, quickly identify critical warning signs, decrease hospital readmissions and reduce healthcare costs for CHF patients by integrating remote monitoring ePRO into standard outpatient care practices. Methods: The pilot study seeks to enroll 60 patients who were admitted to The Mount Sinai Hospital for acute CHF exacerbation and have access to either an Android or iOS enabled smartphone. RxUniverse (a digital platform that enables physicians to directly ``prescribe'' evidence-based mobile health applications to patients) will be used to prescribe HealthPROMISE and iHealth mobile apps (Figure 1). Patients update and record their CHF-related symptoms and quality of life measures daily on HealthPROMISE. Vital sign data, including blood pressure, heart rate, and weight, is collected through an ambulatory remote monitoring system that includes a smartphone application and Bluetooth-connected smart devices. ePRO data is submitted electronically to a dashboard monitored daily by a practitioner, who determines whether to continue current care or to call the patient for further assessment of symptoms (Figure 2). Any critical red-flag values automatically alert the physician and prompt the patient to seek medical attention. Enrollment barriers included: onboarding time (30 minutes), identifying patients, competition with other Mount Sinai initiatives and research trials, language barriers, and low health literacy (Figure 3). Results: The study had 52 of the 60 patients enrolled. Thirty-eight patients (73\%) continue to actively use the mobile apps and smart devices to track blood pressure and weight, 27 patients (52\%) have completed one month of active use, while 5 patients have dropped out. There have been 4 hospital readmissions (7\%) mainly due to non-compliance and complications from other chronic conditions (Figure 3). Conclusions: Given the increasing burden of CHF on patients and healthcare systems, there is a critical need for an effective, sustainable, and feasible remote monitoring system for CHF patients following hospital discharge. The ability for providers to access patient-reported outcomes and vital signs in real-time can significantly impact the quality of outpatient care, potentially reducing readmissions and costs. CHF patients are showing positive health outcomes; CHF patients had a 7\% readmission rate compared to the national readmission rate of >25\% within 30 days of discharge. Enrollment challenges were overcome by enrolling CHF patients 2-3 days before expected discharge and adding a patient coordinator to hospital rounds. These latest advances in remote monitoring show promise for the future of technology-connected healthcare. ", doi="10.2196/iproc.8459", url="http://www.iproc.org/2017/1/e24/" } @Article{info:doi/10.2196/iproc.8453, author="Tam, Anne and Melvin, Emilie and Cushing, Anna and Cohen, Jesse and Manice, Melissa", title="Assessing the Use of Mobile Technology in Adult Asthma Patients: Remote Observational Study", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e19", keywords="asthma", keywords="medication adherence", keywords="mobile health", keywords="mHealth", keywords="mobile health intervention", keywords="mobile phone", keywords="mobile phones", keywords="mobile technology", keywords="mobile text reminders", keywords="patient monitoring", keywords="real-time surveillance", keywords="telehealth", keywords="telemedicine", keywords="text message", keywords="text messages", keywords="text messaging", abstract="Background: The National Institutes of Health Morbidity and Mortality report indicates that as high as 15.6\% of the US population may have asthma. Non-adherence to daily controller medications is a common problem that has been reported to be responsible for 60\% of asthma-related hospitalizations. Mean levels of adherence for asthma medications is estimated to be as low as 22\%. Evidence suggests that patients over-report medication use when asked to self-estimate their adherence. Therefore, objective measurements of adherence to medicine is necessary. Objective: The primary purpose of this study is to determine the feasibility of using the BreatheSmart platform for measuring adherence and whether it improves medication adherence to patients presenting with asthma symptoms who are managed on inhaled corticosteroids. Understanding how patients use the BreatheSmart Platform at home is essential to assess its feasibility as a solution to improve medication adherence in patients using daily inhaled corticosteroids (ICS). We anticipate this approach can be applied to real-world environments as a cost-effective solution to improve treatment plan compliance and patient self management. Secondary objectives include assessment of real-time controller medication adherence and lung function as well as frequency of rescue medication use. The result of this study allowed us to understand the process of implementing the BreatheSmart technology for management of asthma patients and facilitated the pathway to our current larger clinical trial: ``Assessing the Use of Mobile Technology in Adult Asthma Patients: An Observational Study.'' Methods: This is a virtual six-month feasibility study of 20 adults and adolescent with an asthma diagnosis, using ICS for at least 3 months. Participants were recruited in the United States through social media and web-based recruitment. All participants received wireless Bluetooth-enabled inhaler sensors that track medication usage, a mSpirometer capable of clinical-grade lung function measurements, and downloaded the BreatheSmart mobile application which transmits data to a secure server. Participants were randomly assigned to one of two arms regarding lung function measurements in order to assess usability of two different techniques. Usability was assessed by patient questionnaires and opened ended question sessions. Both primary and secondary analyses are based on intention-to-treat (ITT). Results: 100\% of participants interviewed (n=18) wanted to continue using the BreatheSmart app after the study, and would recommend it to a friend with asthma. 93\% of study participants responded positively to their overall experience setting up the app and hardware. Participants had 84.58\% adherence to scheduled doses using their HeroTracker sensors over a 6 month period. Rescue medication usage decreased by 60\% in the first 3 months and 95.3\% through 6 months. We observed an 86\% retention of study participants for the 6-month study duration. (Commonly reported 90-day user retention rates of fitness and health apps: 27--30\%. Conclusions: This study demonstrates that a mobile platform phone application is feasible in enabling patient asthma self-management utilizing a phone-based platform of digital devices and application. Study findings demonstrated a 48\% lift in medication adherence from the baseline national mean medication compliance among asthma patients. Furthermore, use of the BreatheSmart platform was associated with a significant decline in rescue medication usage. Qualitative study participant feedback revealed that high patient retention and motivation to continue on the BreatheSmart platform was influenced by the reliability, simplicity and user friendliness of the platform's design. More than 50\% of the study participants viewed the interactions with the study investigator as a true value add, promoting accountability and enhanced care management. These findings should be further researched with incorporation of clinician remote monitoring to evaluate the impact of the BreatheSmart platform in enhanced clinical decision making at the point of care or between clinic visits. ", doi="10.2196/iproc.8453", url="http://www.iproc.org/2017/1/e19/" } @Article{info:doi/10.2196/iproc.8577, author="Kale, Kaustubh and Alrifai, Abdulah and Kabach, Mohamad and Hakimian, Stephanie and Esfahanian, Mahdi and Pava, Diego and Borzak, Steven and Chait, Robert", title="Cloud Connected Noninvasive Device Correlation with Pulmonary Artery Pressure by Right Heart Catheterization: Implications for Diagnosis and Clinical Practice to Improve Outcomes for Heart Failure Patients", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e34", keywords="heart failure", keywords="remote monitoring", keywords="hospitalization", keywords="quality of life", abstract="Background: The management of 5-6 million Americans with heart failure (HF) is costly and problematic in part due to very high re-admission rates of 25\% within 30 days, and 50\% within 6 months. Clearly needed is a new way to manage these patients without relying on costly hospitalizations. Clinical interventions based on standard tele-monitoring utilizing monitoring of blood pressure, weight, electrocardiograms, or rhythm strips for review, have not demonstrated a significant reduction in all cause readmissions or all cause mortality within 180 days after enrollment. Invasive devices have demonstrated that ambulatory pulmonary artery pressures (PAPs) hemodynamic measurement allow more effective HF management leading to fewer hospitalizations. The HemoTag is a new cloud-connected medical device that captures heart sounds and an ECG signal transduced via 3 thoracic electrodes. The device measures cardiac time intervals and can potentially constitute a quick and non-invasive means of assessing patient's PAP obtained by right heart catheterization. Electromechanical Activation Time (EMAT) as one of the HemoTag indices was assessed as a marker of systolic, and mean PAPs in the right heart measurements. HemoTag indices were then assessed to identify normal/abnormal PAP using prediction models. Objective: Given the clinical and economic impact of HF hospitalizations, and in view of the risk and cost of invasive monitoring, there is a need for a non-invasive, affordable, accurate, and actionable hemodynamic measurement method that can monitor HF patients in the clinic and at home. This study provides preliminary results of HemoTag as a possible solution for remote monitoring of HF patients. Methods: There were 20 consecutive patients recruited at the catheterization laboratory of community affiliated academic center (JFK Medical Center) from February 1 to March 30, 2017 (WIRB approved study \# 20151156). Eight patients were excluded from the study as they did not meet inclusion criteria. EMAT measurements were obtained using HemoTag within 30 minutes from the right heart catheterization. Linear regression and predictive models were employed to evaluate EMAT correlation with systolic and mean pulmonary pressure. Data was entered and analyzed on MS-Excel 2016. Results: The female to male ratio was 0.58 with a mean age 69. 59 +/- 15.63 years. The mean systolic blood pressure was 130 +/- 19.42 mmHg, mean weight was 189.06 +/- 42.32 pounds. The mean of mean pulmonary atrial pressure (mPAP) was 33.09 +/- 14.27 mmHg and mean of systolic pulmonary atrial pressure (sPAP) was 55.25 +/- 23.41 mmHg. Using a linear regression approach, EMAT correlated with mPAP with R value of 0.69 whereas overall correlation between EMAT and sPAP was R=0.65. Using clinically relevant cut-off of 25mmHg for mPAP, a prediction model constructed by logistic regression with confidence interval 0.95 demonstrates a sensitivity of 100\%, specificity of 100\% and accuracy of 100\%. Conclusions: HemoTag represents a potentially widely applicable technology for the assessment of pulmonary artery pressure via a non-invasive approach which can be used in the ambulatory setting or for patients at home. This has a distinct advantage over invasive pulmonary artery monitoring with similar results. Larger studies are needed to confirm the findings of this study. ", doi="10.2196/iproc.8577", url="http://www.iproc.org/2017/1/e34/" } @Article{info:doi/10.2196/iproc.8455, author="de Redon, Emily and Palacholla, Ramya and Golas, Sara and Schussler, Nina and Cortese, Lauren and Odametey, Sharon and Agboola, Stephen and Kvedar, Joseph and Jethwani, Kamal", title="Evaluating the Impact of a Blood Pressure Remote Telemonitoring Program (BP Connect)", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e20", abstract="Background: The prevalence of hypertension is around 30-45\% among the general population. Hypertension contributes to 1 out of 7 deaths in the United States and approximately 70\% of persons who have a first heart attack or stroke. Timely treatment and optimal management of hypertension is associated with substantial reductions in stroke incidence (35-40\%), myocardial infarction (20-25\%), and heart failure (>50\%). Additionally, remote monitoring with active intervention by medical professionals (telemonitoring) improves drug compliance and increase the target blood pressure (BP) achievement rate. Objective: BP Connect is a remote monitoring program to augment care and disease self-management in hypertensive patients. The program aims to engage patients in self-care by providing a secure web-based platform to record and track their BP. In addition, care providers can view the uploaded data, thereby, ensuring the continuum of care beyond the hospital setting. Methods: A total of 288 adult patients diagnosed with hypertension (baseline blood pressure of ?140 mm Hg systolic or ?90 mm Hg diastolic) were recruited from primary care and specialty clinics within the Partners Healthcare network of hospitals (Faulkner, Renal, Endocrinology and Cardiology departments at Brigham and Women's Hospital and Massachusetts General Hospitals Women's Health Association). The primary outcome was the impact of BP Connect on blood pressure as measured by the change in the proportion of patients with controlled BP (ie, <140/90 mm Hg) from the initial visit to the 3-month clinic visit. Secondary outcomes included the change in systolic blood pressure (SBP) and diastolic blood pressure (DBP) at close-out. Results: Among the 149 patients from primary care clinics who completed the program to-date 48.0\% of patients had uncontrolled BP (>140/90 mm Hg) vs 64.0\% at baseline (P=.01). At 3 months, there was a significant decline in the mean SBP (-10.1, P<.01) and the mean DBP (-4.3, P<.01). Among the 139 patients from specialty clinics who completed this program, BP was controlled at 3 months in 43.2\% of patients compared with 11.2\% patients at baseline (P=.001). A significant decrease in the mean SBP (-5.2, P<.001) and in the mean DBP (-2.5, P=.01) were also noted. Conclusions: Overall, the BP Connect program shows potential to improve clinical outcomes in hypertensive patients. The program provides an opportunity for participants to track their BP measurements on a web platform to foster patient participation in their own disease management that may improve patient outcomes and decrease burden on the care providers. ", doi="10.2196/iproc.8455", url="http://www.iproc.org/2017/1/e20/" } @Article{info:doi/10.2196/iproc.8454, author="Muller, Matt", title="A Safer Transition From the Emergency Room: Using Telemedicine to Reimagine the Er Visit", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e29", keywords="emergency department", keywords="telemedicine", keywords="post-acute care", keywords="continuity of care", abstract="Background: The week following ER discharge is often a challenging time for patients---whether as a result of continuing symptoms, anxiety about symptom progression, inability to access follow-up care, or remaining questions related to treatment plan or prescriptions. All have repercussions for patient safety, care quality, and satisfaction with service. Patient-centric solutions for continuity of care during this period are rare, and return visits to the ER are common. With this in mind, Emergency Medicine Consultants (EMC) re-imagined the ER visit using telemedicine to transform the 3-hour ER visit into a week-long patient relationship. Objective: The pilot aimed to evaluate the effectiveness of a text-based telemedicine platform to provide post-acute care to patients who recently received acute care in emergency departments of several Dallas-area hospitals. Methods: Through a partnership with CirrusMD, EMC piloted 24/7 direct, continual patient access to emergency physicians via a HIPAA-compliant, text-first virtual care platform following discharge from the ER at no cost to the patient. By the end of the pilot, the service was being offered to 30,000 patients a month at 12 hospitals in the Dallas-Ft Worth metroplex. Results: The Safe Transitions program is achieving the triple aim of improved safety, service, and resource utilization. In the first six months of the pilot, 2,700 follow-up virtual encounters were completed, involving almost 2,000 patients. Median response time to initial patient inquiry by a physician was two minutes, with median duration of patient encounters spanning 40 minutes. Nearly 80 percent of patients who registered for the service used it, with 25 percent of patients on the platform having multiple encounters over the 7-day period. Resolution of patient issues occurred in 84 percent of encounters without brick-and-mortar referral, with additional prescriptions written in 15 percent of encounters. Service levels led 90 percent of surveyed patients to indicate that having access to Safe Transitions ``improved'' their experience with the health system, and 90 percent said they were more likely to recommend the health system to friends and family because of Safe Transitions. Conclusions: Telemedicine following acute care episodes improves access and continuity of care, improves care quality, and patient experience, while reducing avoidable utilization. ", doi="10.2196/iproc.8454", url="http://www.iproc.org/2017/1/e29/" } @Article{info:doi/10.2196/iproc.8452, author="Atreja, Ashish and Otobo, Emamuzo and Chang, Helena and Keefer, Laurie and Rogers, Jason and Ullman, Thomas and Ramireddy, Karthik and Marion, James and Deorocki, Allyssa and Berde, Ed and Zlatopolsky, Rivelle and Kohli, Akshay and Choksi, Pavan and Itzkowitz, Steven and Colombel, Jean-Fred and Sands, Bruce", title="HealthPROMISE: Utilization of Patient Reported Outcomes to Measure Quality of Life in Inflammatory Bowel Disease", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e28", keywords="Quality of life", keywords="Self-Management", keywords="Inflammatory Bowel Disease", keywords="Remote Monitoring", keywords="Electronic Patient Reported Outcome", abstract="Background: Inflammatory Bowel Disease (IBD) is a chronic condition of the bowel affecting over 1.5 million people in the United States. The recurrent nature of IBD makes affected patients ideal candidates for electronic patient reported outcome (e-PRO) monitoring that centers on enhanced symptom tracking and improved communication with care teams. Objective: The study aims to understand the impact of e-PRO utilization via a prescribed mobile application, HealthPROMISE, on improving patients' quality of life (QOL). Researchers investigated patients' use of e-PROs to determine whether physicians change treatment in response to new patient health information, and whether patients' quality of life changes over the course of the study. Methods: In a pragmatic randomized trial at Mount Sinai Medical Center (MSMC), baseline e-PROs were measured using online questionnaires delivered through the app that assessed health literacy, disease severity, general health status, and demographic information. Patients using HealthPROMISE could update their e-PRO information and receive a disease summary and a graph trending IBD-specific QOL scores (Figure 1). Patients could also communicate over the HealthPROMISE app and discuss results with providers. Results of e-PRO data were then compared with those collected from paper-based instruments in another institution (University of Pittsburgh Medical Center, UPMC) for triangulation (Figure 2). Results: There were 320 patients enrolled in the study. Of these, 162 were randomized to the intervention group (e-PROs), and 158 to the control group. Fatigue and tension were the two most important drivers of poor QOL in both MSMC and UPMC cohorts. Usage data showed that the majority of patients ({\textasciitilde}75\%) continue to actively log into the HealthPROMISE app and update their e-PRO. Overall, QOL improved among HealthPROMISE patients over a mean follow-up of 6 months. At baseline, patients in the intervention arm reported a mean quality of life score of 30.3 {\textpm} 11.3. The last available follow-up QOL scores showed improvement among patients using HealthPROMISE to 25.3 {\textpm} 11.3 (P<0.001) (Figure 2). Conclusions: This is one of the first randomized controlled trials of app-based PRO measure in IBD patients. A significant improvement in QOL was observed. Longitudinal e-PRO collection in IBD patients is feasible with a high degree of adoption and engagement. IBD patients who participate in their own care (via PRO) and share in decision-making have appreciably improved outcomes when compared to patients who do not. ", doi="10.2196/iproc.8452", url="http://www.iproc.org/2017/1/e28/" } @Article{info:doi/10.2196/iproc.8451, author="Melmed, Ari", title="Chat with a Doctor: Using Asynchronous Virtual Care Access for On-Demand Physician Advice", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e18", keywords="telemedicine", keywords="virtual acute care", keywords="cost of care", abstract="Background: As an HMO, responsible for all medical costs of their member patients, Kaiser Permanente Colorado, like most providers, struggle with access: patients want to be seen by a clinician quickly and when they can't get an appointment in a timely manner, patients tend to go to higher-cost points-of-care (including the emergency department, urgent care, and other brick-and-mortar facilities), leading to enormous costs for Kaiser. A solution was needed that would bridge that gap to instantly address their patients' needs at a lower cost. Prior to launching Chat with a Doctor, Kaiser Permanente Colorado had several virtual care options in place to help connect patients with their doctor. This included emailing a doctor, scheduled phone calls, eVisits, and scheduled video calls. These options provided varying quality of resolution and most had underwhelming utilization metrics. Objective: The pilot aimed to evaluate the effectiveness of a text-based telemedicine platform providing on-demand physician access to patients in Colorado in treating patients in a timely manner and thereby reducing unnecessary utilization of high-cost points-of-care. Methods: Kaiser Permanente Colorado offered direct, continual patient access to family medicine and emergency medicine physicians via a HIPAA-compliant, text-first virtual care platform which was fully integrated with Kaiser Permanente Colorado's patient portal. The service is being offered to nearly 660,000 member patients in the state of Colorado. Results: In its first few months, Kaiser Permanente Colorado physicians have effectively diagnosed and treated a wide array of conditions with Chat with a Doctor. Over 12,500 encounters were completed in the first seven months on the platform with the number continuing to grow as marketing efforts around the program ramp up. Seventy-nine percent of chat encounters are handled with advice only or a prescription, while 18 percent are referred for appointments in the Kaiser Permanente Colorado system, and one percent are referred to the ED. Additionally, encounters on the Chat with a Doctor program resulted in 54 percent fewer in-person visits to brick-and-mortar facilities during the seven days following a virtual encounter when compared to the nurse call line. In all, encounters cost Kaiser Permanente Colorado 48 percent of the cost of their nurse call line, and just two percent of the cost of an emergency department visit. As an added bonus, patient satisfaction and likelihood to recommend are extremely high, outperforming other care channels in KP Colorado because the solution improves overall patient engagement by providing a responsive service for patients to access care and answers to their questions. Conclusions: Implementing an asynchronous virtual care platform improves access, care quality, and patient experience, while reducing avoidable utilization and overall costs of care. ", doi="10.2196/iproc.8451", url="http://www.iproc.org/2017/1/e18/" } @Article{info:doi/10.2196/iproc.8447, author="Pantelopoulos, Alexandros and Faranesh, Anthony and Milescu, Andreea and Hosking, Paige and Venkatraman, Subramaniam and Heneghan, Conor", title="Screening of Atrial Fibrillation Using Wrist Photoplethysmography from a Fitbit Tracker", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e17", keywords="cardiovascular disease", keywords="screening", keywords="atrial fibrillation", abstract="Background: Atrial Fibrillation is the most common clinically significant cardiac arrhythmia, estimated to affect between 2\% (< 65 years of age) and 9\% (> 65 years of age) of the U.S. population. Screening and early detection of AF can help prevent associated stroke and cardiovascular disease. Commonly used monitoring devices are limited to short periods (< 4 weeks) and are usually employed in symptomatic subjects. Wrist-worn wearables equipped with photoplethysmography (PPG) could potentially aid in AF screening, as they can be easily worn by most people for extended periods of time. Objective: This study aimed to investigate the ability of wrist-based PPG to detect the presence of AF in subjects while at rest. Methods: This study was conducted with the approval of local institutional review boards, and all patients provided written, informed consent. The first dataset consisted of 9 patients with persistent AF and 13 subjects with normal sinus rhythm. For these 22 subjects, PPG and ECG data were collected while sitting stationary for 15 minutes (awake dataset). A second dataset consisted of 10 patients with persistent AF and 27 subjects with no known diagnosis of AF. These subjects were asked to wear a Fitbit wrist-band which recorded PPG and accelerometry data during sleep (sleep dataset, 73 total nights). There was no overlap between subjects in the awake and sleep datasets. Results: Data were analyzed in overlapping 1 or 5-minute windows. Pulse Rate Variability (PRV) features, PPG morphology features and accelerometer features were extracted for each window. An algorithm was trained on the awake dataset and was validated on the sleep dataset. The performance was 95.7\% (98\%) sensitivity (Se) and 0.8\% (0.8\%) False Positive Rate (FPR) for 1 min (5 min) windows. We also investigated the shortest duration of an AF episode that could be detected by using synthesized data. With 1 minute analysis windows, the algorithm was sensitive down to 40-second episodes. Using 5-minute intervals, episodes down to 3 minutes could be reliably detected. Conclusions: Wrist-bands equipped with PPG sensors can be used to detect atrial fibrillation during sleep or during awake, stationary periods. While reliable detection of short AF episodes can be challenging due to the noisy nature of PPG signals, we have demonstrated that select PPG features can enable accurate detection of AF down to 40 second periods. These findings suggest that wrist-worn devices equipped with a PPG sensor could be used to screen for AF in high-risk subjects or monitor patients post treatment, but are limited to cases where users are not moving or exercising. Additional, larger clinical studies are planned for the future to validate these promising early results and to validate the algorithm's specificity against other forms of arrhythmia. ", doi="10.2196/iproc.8447", url="http://www.iproc.org/2017/1/e17/" } @Article{info:doi/10.2196/iproc.8445, author="Caplan, Emily and Schussler, Nina and Gabbidon, Harriett and Cortese, Lauren and Maclean, Erick and Gorman, Colin and Moore, Marianne and Barr Vermilya, Holly and Agboola, Stephen and Jethwani, Kamal and Kvedar, Joseph", title="Partners eCare Research Core for Clinical Research: Pilot to Build and Test Silent Best Practice Alert Notifications for Recruiting Inpatient Study Participants", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e16", keywords="electronic health record", keywords="innovation", keywords="participant recruitment", abstract="Background: Participant recruitment remains one of the greatest challenges for many research groups. For an observational prospective study of objective and subjective measures in outpatients with chronic obstructive pulmonary disease (COPD) to assess clinical deterioration (Emerald-COPD) at Partners Connected Health, recruiting COPD patients from the inpatient setting was inefficient and low-yielding. To screen for eligible participants, Research Coordinators spent over two hours per day manually searching through the EPIC Reporting Workbench from three hospitals and reviewing admission notes to determine whether patients met eligibility criteria. Objective: This pilot project, conducted in collaboration with Partners eCare Research Core (PeRC), examines a new EPIC functionality built to support inpatient recruitment for clinical trials. The silent Best Practice Alert (BPA) system identifies potentially eligible participants in real time to help research teams maximize recruitment accuracy and efficiency of resources. Methods: This out-of-the-box solution alerts study staff of the inpatient admission of potential participants through EPIC In-Basket messages. The silent BPA notifications detect an event of interest, in this case hospital admissions, using criteria pre-selected by Emerald-COPD research staff. Criteria included: patient class, admit diagnosis, prescribed medications, and presence of COPD on the EPIC problem list; these were used to flag potential participants at multiple Partners hospitals. We hypothesized that this tool would reduce the daily screening time, the number of missed potential participants as well as the time needed to recruit the targeted number of patients. Results: To date, there have been 171 potentially eligible patients identified through BPA notifications. Of those, we have enrolled 26 participants into the Emerald- COPD study. Since implementation, there have been an average of 3 additional patients each week that were missed during our previous method of screening. In addition to expanding the pool potential participants, this tool has decreased screening time for Research Coordinators. The silent BPA screening method has proven to be 4 times faster than our previous screening method, projected to save 442.5 hours over the duration of the study. Conclusions: Automation of the recruitment process has allowed us to identify potential participants in real time and avoid missing patients. This has made a substantial impact in raising our enrollment numbers. Silent BPA screening is a considerably faster method which allows for Research Coordinators to devote more time to other important aspects of research such as retention of enrolled participants. When time is allocated effectively, the study can run smoothly and be more cost effective. The outcomes have all been favorable, notably our experience working with the PeRC team. From the build process to implementation, the team was responsive and engaged. This was essential to the speed of production and our encouraging progress. This innovative and instrumental functionality can be specified to the needs of other clinical research groups hoping to utilize EPIC for participant recruitment. ", doi="10.2196/iproc.8445", url="http://www.iproc.org/2017/1/e16/" } @Article{info:doi/10.2196/iproc.8426, author="Shah, Lochan and Marvel, Francoise and Spaulding, Erin and Yang, William and Xun, Helen and Merali, Farhan and Lee, Matthias and Martin, Seth", title="Harnessing Connected Health to Improve Hospital Discharge and Patient Outcomes for Every Generation: Insights from Piloting the Corrie Platform in Post-MI Recovery", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e27", keywords="myocardial infarction", keywords="smartphone application", keywords="wearables", keywords="smartwatch", keywords="self-management", keywords="hospital discharge", keywords="clinical care", keywords="patient empowerment", keywords="cardiology app", abstract="Background: Rapid adoption of smartphones has led to an increasing interest in connected health interventions for clinical care and remote monitoring. However, there is a large disconnect between clinical patient populations and the digital health literature, as most digital health work has occurred outside the healthcare system in younger, healthy patients. The applicability of many innovative connected health approaches across generations, particularly in older patients presenting with coronary heart disease, is a topic in strong need of further study. Our interdisciplinary team of clinicians and engineers built the 1st cardiology CareKit application (``Corrie''), focused on improving hospital discharge and empowering patients from all generations through an optimal recovery from acute myocardial infarction. We now report on our initial piloting experience with a focus on use and outcomes across generations. Objective: In this interim analysis of the first 47 patients enrolled in the Myocardial infarction COmbined device Recovery Enhancement (MiCORE) Pilot Study, we sought to assess the feasibility and uptake of a connected health platform in patients hospitalized with acute myocardial infarction (AMI) and to assess 30-day post-discharge readmission risk across generations. Methods: This prospective observational study enrolled acute MI patients from the Cardiac Units at two sites--Johns Hopkins Bayview and Johns Hopkins Hospital. The intervention, consisting of an Apple CareKit smartphone application (``Corrie app'') and Apple smartwatch, allowed patients to develop medication self-management skills, coordinate follow-up appointments, learn about critical preventative cardiology topics via videos, and connect with health resources across the continuum of care. AMI patients were enrolled during admission and used the intervention from enrollment through 30-days post-discharge. The intervention was developed with substantial efforts to optimize user-centered design. 30-day readmission rate was assessed by chart review of electronic medical record and CRISP regional data. Descriptive statistics were performed to examine user demographics. Results: 30-day readmission rates in Corrie-enrolled patients (0\%, N=47) were significantly lower than the Johns Hopkins historical control (19\%, N=200; P<0.001). 70.2\% of Corrie patients were men and 29.8\% were women, with roughly half of the patients above the age of 60 (46.8\%). The mean age was 58 (SD 11), with a full range from 32-76 years. Patients represented all generations: 8.5\% were from the Silent Generation (born before 1945), 55.3\% were Baby Boomers (born 1945-1964), 31.9\% were from Generation X (born 1964-1980) and 4.3\% were Millennials/Generation Y (born 1980-1999). The proportion of White/Caucasian participants was 68.1\%, Black/African American was 14.9\%, American Indian/Alaska native was 2.1\%, Asian was 4.2\%, and unknown/other was 10.6\%. Examining socioeconomic status, 10.7\% had Medicaid, 8.5\% had Medicare, 78.7\% had private insurance, and 2.1\% had no insurance. The average median income according to patient zip codes was \$74,717. Conclusions: In our study that stands out for its focus on deployment of patient-centered connected health in the clinical care setting, the Corrie platform shows evidence of uptake, feasibility, and effectiveness of digital health interventions across patients of multiple generations and demographics. Additional studies are ongoing to evaluate differential user engagement between demographic groups with respect to specific features of the smartphone-application based intervention. ", doi="10.2196/iproc.8426", url="http://www.iproc.org/2017/1/e27/" } @Article{info:doi/10.2196/iproc.8410, author="Simons, Mariana and Golas, Sara and Agboola, Stephen and op den Buijs, Jorn and Fischer, Nils and Felsted, Jennifer and Schertzer, Linda", title="Healthcare Cost Analysis of Older Patients Using a Personal Emergency Response Service Uncovers Costs Savings Opportunity", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e26", keywords="Healthcare cost analysis", keywords="Cost acuity pyramid segmentation", keywords="Personal Emergency Response Service (PERS)", abstract="Background: In the US healthcare system, half of overall Medicare and Medicaid Services reimbursement goes towards caring for the top 5\% most expensive patients. However, little is known about how these patients' costs change annually prior to them reaching the top 5\%. To address these gaps and investigate potential cost savings opportunities, we analyzed patient flow and associated healthcare cost trends over the period 2011-2015. Objective: To evaluate longitudinal trends in healthcare cost of older patients using Personal Emergency Response Service (PERS). Methods: This is a retrospective, longitudinal, multicenter study to evaluate healthcare cost of 2,643 older patients over the period 2011-2015. All patients had at least one inpatient and/or outpatient encounter, and at least one episode of home health care during the study period. In addition, all patients used PERS at home anytime during the study period. The study population was segmented by their annual healthcare expenditures into Top (5\%), Middle (6-50\%) and Bottom (51-100\%) segments. Cost acuity pyramids were built based on these segments for each fiscal year. The longitudinal healthcare expenditure trends of the complete study population, as well as each segment, were assessed by linear regression models. Patient flows throughout the segments of the cost acuity pyramids from year to year were modeled by Markov chains. The associated costs flows were quantified over a 2-year period. Results: Total healthcare cost of the study population nearly doubled from \$17.7M in 2011 to \$33.0M in 2015. This increasing trend was statistically significant (P=0.003) with an expected yearly cost increase of \$3.6M. This growth was driven by a significantly higher cost increase in the Middle segment (\$2.3M; P=0.002). The expected yearly costs increase of the Top and Bottom segments was \$1.2M (P=0.008) and \$0.1M (P=0.003) respectively, and both were statistically significant. The patients and cost flow analyses showed that 18\% of patients moved up the cost acuity pyramid yearly, and their cost increased by 672\% in contrast to 22\% of patients who moved down with a cost decrease by 86\%. The remaining 60\% of patients stayed in the same segment from year to year, but their cost increased by 18\%. Conclusions: While many healthcare organizations target costly intensive interventions for their most expensive patients, this analysis unveiled a potential cost savings opportunity by managing the patients in the lower cost segments that are at risk of moving up the cost acuity pyramid. To achieve this, data analytics that integrate longitudinal data from the EHR and home monitoring devices may help healthcare organizations to optimize resources by enabling clinicians to proactively manage patients in their home or community environments, beyond institutional settings and 30-60 day telehealth services. ", doi="10.2196/iproc.8410", url="http://www.iproc.org/2017/1/e26/" } @Article{info:doi/10.2196/iproc.8389, author="Edwards, Colin and Cassidy, Nicola and Costello, Eamonn and Russell, Anne-Marie", title="Pilot Study to Test the Utility and Acceptability of An Electronic Health Record (patientMpower) for Patients With Lung Fibrosis", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e10", keywords="dyspnea", keywords="electronic symptom reporting", keywords="lung diseases", keywords="patient-reported outcomes", keywords="spirometry", keywords="IPF", abstract="Background: Idiopathic pulmonary fibrosis (IPF) is an irreversible condition associated with progressive dyspnoea, fatigue, cough and psychological distress. Progression of IPF impacts physical activities affecting quality of life. Forced vital capacity (FVC) is the internationally accepted spirometry marker of disease progression. The patientMpower platform promotes supported self-management, enabling patients with IPF to record relevant objective and subjective measurements and health outcomes. Objective: Assess patients' views on the utility and acceptability of the patientMpower platform in lung fibrosis. Methods: Thirteen patients with lung fibrosis participated in a prospective, single-arm observational study (6 weeks). Invitations were issued through the Irish Lung Fibrosis Association. There were no changes to usual healthcare. Patients independently installed the patientMpower platform to their own smartphone/tablet. Technical support was available if needed. All patients were supplied with a Spirobank Smart spirometer (MIR, Rome, Italy) to record FVC at home. Instruction on correct use of the spirometer was given, supported by instructional video content within the platform. Patients were asked to use the patientMpower platform regularly, ideally daily. Measurements included: modified Medical Research Council breathlessness scale (mMRC), medication compliance, daily spirometry (seated), step count and weekly impact of lung fibrosis on daily life [Patient Reported Outcome Measure (PROM)]. Patients' opinions on utility and acceptability were assessed by a 17-point questionnaire. Results: 13 patients (7 male; 54\%) participated. Median age: 66 years (range 37-83). Median baseline FVC: 78\% predicted (range 40-123\%). Twelve patients (92\%) used the patientMpower platform for ?6 weeks and 8 (61\%) completed feedback questionnaires. 87\% of patients (n=7/8) who provided feedback questionnaires reported their experience of the platform as ``positive'' and stated they wanted to continue using it. To date, 8 patients (61\%), continue to actively use the platform after study completion. Nine patients (69\%) used the platform within 5 days of download and twelve used it on ?60\% of days over the observation period. Three patients (23\%) used it every day. Home spirometry was recorded frequently (median 69\% of days; range 21-83\%). mMRC data was infrequently recorded (0-7\% of days). Impact of lung fibrosis on daily life (PROM) was completed frequently (median 67\% of weeks). At baseline, 12 patients (92\%) reported that breathing difficulties related to IPF affected their quality of life ``some of the time'' or ``most of the time''. Conclusions: Patients with a severe life-limiting lung condition are willing and able to use an electronic health record to record objective data, symptoms and outcomes. Age is not a barrier to engaging with this technology. Regular home spirometry and recording of impact of lung fibrosis on daily life was feasible and acceptable in this patient population. A majority wished to continue using patientMpower indefinitely. This approach may be useful to capture patient-reported long-term trends in FVC and health outcomes. ", doi="10.2196/iproc.8389", url="http://www.iproc.org/2017/1/e10/" } @Article{info:doi/10.2196/iproc.8359, author="Iacoviello, Brian and Shin, Daniel and Kruse, Gina and Steinerman, Joshua and Schork, Nicholas", title="Adherence to Smoking Cessation Medications Among Clickotine? Users", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e9", keywords="applications", keywords="eHealth, health promotion", keywords="medication adherence", keywords="smoking cessation", abstract="Background: Tobacco smoking is the leading cause of preventable death in the US, with the economic burden attributable to smoking exceeding \$300 billion annually. Although smoking cessation medications are effective in clinical trials, their real-world effectiveness is sub-optimal. Poor adherence to smoking cessation medications is associated with failed quit attempts. Technology has been used to promote medication adherence in other conditions. Clickotine is a science-based mobile application for smoking cessation, designed to assist smokers according to the US Public Health Service Clinical Practice Guidelines. Clickotine has been tested in a single arm trial and shows promise as a smoking cessation aid. One core component of the Clickotine program aims to educate smokers about smoking cessation medications including nicotine replacement therapy, varenicline, and bupropion and to facilitate access and adherence to these medications through targeted Clickotine missions and personalized messages. Clickotine missions direct the user to do something specific related to their quit journey. Missions related to smoking cessation medications included ``read here to learn about NRT options and efficacy''; ``set a reminder to take your meds''; or ``make a plan to order your refill.'' Personalized messages provide encouragement and reminders and included information relevant to the user or their quit journey. Objective: To measure use of smoking cessation medications among Clickotine users and measure medication adherence at baseline and 8-weeks in a single-arm trial of Clickotine for smoking cessation. Methods: U.S. residents between 18-65 years of age who owned an iPhone and smoked 5 or more cigarettes daily were recruited via online advertising from May to July 2016. Respondents were pre-screened for eligibility by telephone and directed to a web portal to complete informed consent, confirm eligibility, and download the Clickotine app. Participants completed study assessments via the web portal at baseline and after 8-weeks (primary outcome). The proportion of participants using a smoking cessation medication was measured at baseline and at the 8-week outcome. To assess adherence to smoking cessation medications, the Morisky Medication Adherence Scale- 4 item version (MMAS-4) was compared at baseline and study outcome. MMAS-4 yields scores of 0-4 with greater scores indicating decreased adherence. Results: 416 participants downloaded the app and constituted the intention-to-treat (ITT) sample in the Clickotine trial. Of these, 31 (7.5\%) reported using a smoking cessation medication at baseline. At 8 weeks, 68 participants (16.3\%) reported using a smoking cessation medication. Increases were observed for all medications (e.g., medications (varenicline or bupropion): 183\%; NRT: 93\%) and subcategories (e.g., varenicline: 233\%; nicotine gum: 200\%). MMAS-4 score at baseline (mean = 2.35; SD= 1.43) was significantly greater than the MMAS-4 score observed at study outcome (mean = 1.28; SD= 1.31), t(87)= 3.30, P=.001, and Chi-square analysis of distribution of MMAS-4 scores indicated a shift toward greater adherence from study baseline to outcome (2(4)= 10.56, P=.032). Conclusions: Access and adherence to smoking cessation medications increased during an 8-week, single-arm clinical trial of Clickotine. ", doi="10.2196/iproc.8359", url="http://www.iproc.org/2017/1/e9/" } @Article{info:doi/10.2196/iproc.8358, author="Alwashmi, Meshari and Hawboldt, John and Davis, Erin and Marra, Carlo and Gamble, John-Michael and AbuAshour, Waseem", title="The Effect of Smartphone Interventions on Patients With Chronic Obstructive Pulmonary Disease Exacerbations: Systematic Review and Meta-Analysis", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e6", keywords="meta-analysis", keywords="systematic review", keywords="telemedicine", keywords="pulmonary disease", keywords="chronic obstructive pulmonary disease", keywords="ehealth", keywords="mhealth", keywords="chronic disease", abstract="Background: The prevalence and mortality rates of chronic obstructive pulmonary disease (COPD) are increasing worldwide. Therefore, COPD remains a major public health problem. There is a growing interest in the use of smartphone technology for health promotion and disease management interventions. However, the effectiveness of smartphones in reducing the number of patients having a COPD exacerbation is poorly understood. Objective: To summarize and quantify the association between smartphone interventions and COPD exacerbations through a comprehensive systematic review and meta-analysis. Methods: A comprehensive search strategy was conducted across relevant databases (PubMed, Embase, Cochrane, CINHA, PsycINFO, and the Cochrane Library Medline) from inception to October 2015. We included studies that assessed the use of smartphone interventions in the reduction of COPD exacerbations compared with usual care. Full-text studies were excluded if the investigators did not use a smartphone device or did not report on COPD exacerbations. Observational studies, abstracts, and reviews were also excluded. Two reviewers extracted the data and conducted a risk of bias assessment using the US Preventive Services Task Force quality rating criteria. A random effects model was used to meta-analyze the results from included studies. Pooled odds ratios were used to measure the effectiveness of smartphone interventions on COPD exacerbations. Heterogeneity was measured using the I(2)statistic. Results: Of the 245 unique citations screened, 6 studies were included in the qualitative synthesis. Studies were relatively small with less than 100 participants in each study (range 30 to 99) and follow-up ranged from 4-9 months. The mean age was 70.5 years (SD 5.6) and 74\% (281/380) were male. The studies varied in terms of country, type of smartphone intervention, frequency of data collection from the participants, and the feedback strategy. Three studies were included in the meta-analysis. The overall assessment of potential bias of the studies that were included in the meta-analysis was ``Good'' for one study and ``Fair'' for 2 studies. The pooled random effects odds ratio of patients having an exacerbation was 0.20 in patients using a smartphone intervention (95\% CI 0.07-0.62), a reduction of 80\% for smartphone interventions compared with usual care. However, there was moderate heterogeneity across the included studies (I(2)=59\%). Conclusions: Although current literature on the role of smartphones in reducing COPD exacerbations is limited, findings from our review suggest that smartphones are useful in reducing the number of patients having a COPD exacerbation. Nevertheless, using smartphones require synergistic strategies to achieve the desired outcome. These results should be interpreted with caution due to the heterogeneity among the studies. Researchers should focus on conducting rigorous studies with adequately powered sample sizes to determine the validity and clinical utility of smartphone interventions in the management of COPD. ", doi="10.2196/iproc.8358", url="http://www.iproc.org/2017/1/e6/" } @Article{info:doi/10.2196/iproc.8295, author="Damania, Dhwanil", title="Continuous Remote Monitoring of Vital Signs in Pediatric Population", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e5", abstract="Background: Wearable sensor technologies coupled with secure patient portals allow for continuous real-time data acquisition from a patient in a hospital or home setting. This combination renders more effective health-management system with faster patient-recovery times and reduced healthcare costs. VitalConnect Inc. has developed a fully-disposable, FDA-cleared (for adults) wireless biosensor (VitalPatch?) that is worn on chest. VitalPatch captures multiple medical-grade biometrics and transmits the physiological data continuously (via Bluetooth) for up to 96 hours to a relay (tablet, wireless hub). Like adults, pediatric patients (5-17 years of age) could also benefit from such small and low-profile biosensor that can collect and stream vital signs uninterruptedly to a secure patient-portal. This data can then be monitored by a clinical triage center or healthcare-provider. Objective: Continuous remote monitoring of heart rate (HR) and breathing rate (BR) is critical during acute or chronic illnesses. The primary purpose of this study was to evaluate the performance of the VitalConnect platform in pediatric subjects during activities of daily living (ADL) to confirm accuracy of sensor measurements for HR and BR with respect to a clinical reference device, Capnostream20 (Oridion). Additionally, information on comfort and usability of VitalPatch at home was assessed for the total duration of wear. Methods: Thirty-five children were enrolled in the study (24 between 9-17 years, 11 between 5-8 years). All subjects participated in 96-hour wear-period of the VitalPatch biosensor and performed one hour of in-lab protocol on Day1 of the wear duration. Each participant underwent stationary breathing exercises (spontaneous, metronome), ADLs with postural maneuvers and treadmill walking. The study was conducted in presence of a nurse after approval from Institutional Review Board. The performance of heart rate, respiration rate, posture and number of steps were assessed for each subject separately using the mean absolute error (MAE) between the true and measured values. The reference for posture and step count was manual observation. Results: During the stationary condition, MAE (across 35 children) for HR and BR was 2.1{\textpm}1.0 beats per minute (BPM) and 2.2{\textpm}0.8 breaths per minute (BrPM) respectively compared to Capnostream20. During ADLs, MAE was 4.3{\textpm}2.7 BPM for HR and 3.7{\textpm}1.7 BrPM for BR. Accuracy of posture (standing, supine, walking) was >93\% and step-count was >95\% overall. Moreover, 80\% participants rated wearing VitalPatch `comfortable' without any itchiness during 96-hour wear. Conclusions: The VitalPatch biosensor demonstrated clinically-acceptable accuracy compared to a standardized reference device for both heart rate and breathing rate. It also provided sufficiently accurate measures for activity in terms of posture and number of steps. Furthermore, when used for up to 4 days at home, there were no adverse events (i.e. rashes, dermatitis, mechanical skin injury) and user experience was satisfactory. The accuracy of vitals and ease-of-use in the home environment in children aged 5-17 illustrate the potential of VitalPatch as a non-invasive and cost-effective vital sign monitoring alternative. VitalPatch biosensor can be integrated into state-of-art devices to monitor vital signs for pediatric patients with diseases like congenital heart abnormalities and adolescent fatigue. ", doi="10.2196/iproc.8295", url="http://www.iproc.org/2017/1/e5/" } @Article{info:doi/10.2196/iproc.8519, author="op den Buijs, Jorn and Simons, Mariana and Fischer, Nils and Golas, Sara and Felsted, Jennifer and Schertzer, Linda and Agboola, Stephen", title="Predictive Modeling of Emergency Hospital Transport Based on a Personal Emergency Response System (PERS): Comparison to Clinical Outcomes", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e32", abstract="Background: With the worldwide increase in the elderly population, chronic diseases and associated healthcare utilization such as costly emergency department visits and subsequent hospitalizations are also on the rise. Predictive analytics can be used to identify patients at high risk for emergency utilization, using Electronic Health Record (EHR) data collected before or at hospital discharge. In addition, non-hospital data may be useful for prediction of changes in risk outside of hospital settings. Inexpensive monitoring of elderly via a Personal Emergency Response System (PERS) to identify patients at high risk for emergency hospital transport could be used to target interventions and prevent avoidable, costly long-term healthcare utilization. Objective: The objectives were 1) to develop and validate a predictive model of 30-day emergency hospital transport based on PERS data; and 2) to compare its predictions with clinical outcomes derived from the EHR. Methods: De-identified medical alert pattern data of 290,434 subscribers to a PERS service were used to build a gradient tree boosting-based predictive model of 30-day hospital transport, including predictors derived from subscriber demographics, self-reported medical conditions, caregiver network information, and up to two years of retrospective medical alert data. Model performance was evaluated on an independent validation cohort (n=289,426). EHR and PERS records were linked for 1,815 patients from the Partners HealthCare at Home program, to compare PERS-based risk scores with rates of emergency encounters as recorded in the EHR. Results: After feature selection, the predictive model of 30-day emergency hospital transport included 121 predictors. Previous recent incidents and emergency encounters were among the most important variables in the predictive model. Predictors also included the number of self-reported medical conditions, and COPD, CHF, and heart conditions specifically. Other important predictors included age, gender, and the number of responders. Goodness-of-fit test and calibration plot indicated that the model predicted probabilities matched with observed outcomes across ranges of predicted risk. Performance of the predictive model of emergency hospital transport, as evaluated by area under the receiver operator characteristic curve (AUC), was 0.78. In the top 1\% predicted high-risk patients, the risk of having one or more emergency hospital transports in the next 30 days was 11.6 times higher than in the overall population. Comparison with clinical outcomes from the EHR showed 3.9 times more emergency encounters in predicted high-risk patients compared to low-risk patients in the year following the prediction date. Conclusions: Remotely collected patient data, facilitated by personal health technologies, can be used to reliably predict utilization outcomes. These predictive analytics tools can be used by healthcare organizations to extend population health management into the home. By timelier identifying of high-risk patients, interventions can be targeted to them. This could lead to overall improved patient experience, higher quality of care and more efficient resource utilization. Future studies could explore the impact of combined EHR and PERS data on predictive accuracy. ", doi="10.2196/iproc.8519", url="http://www.iproc.org/2017/1/e32/" } @Article{info:doi/10.2196/iproc.8469, author="Faoro, Nicholas and McDonald, Meghan and Lyu, Heather and Fenelon, Lorraine and Lydon, Patricia and Kreitzman, Kevin and Fraai, Michael and Salim, Ali and Landman, Adam", title="Implementation of a RFID Tracking System to Capture Trauma Attending Arrival Times in the Emergency Department", journal="iproc", year="2017", month="Sep", day="22", volume="3", number="1", pages="e31", keywords="emergency department", keywords="RFID", keywords="trauma", keywords="american college of surgeons", abstract="Background: Critically injured patients arriving to the Emergency Department (ED) require activation of the trauma team. Patient acuity determines the level of team activation required. For the highest level of acuity, the American College of Surgeons (ACS) Committee on Trauma (COT) mandates that an Attending Trauma Surgeon be present in the ED within fifteen minutes of patient arrival in at least 80\% of encounters. Poor compliance with EMR documentation of attending trauma surgeon arrival times to the ED placed Level 1 Trauma Center verification at risk for a major academic medical center. We developed an objective, automated system for documenting trauma team arrival times, utilizing Radio Frequency Identification (RFID) beacons in the ED. Objective: Developing and testing a sustainable, objective system for measuring trauma team compliance with ACS activation requirements in the ED of a Level 1 Trauma Center. Methods: Our team developed and trialed a system using RFID beacons as a means to triangulate badges worn by trauma faculty when responding to team activations in the ED. Revisions were made to pre-existing RFID hospital infrastructure used for equipment tracking purposes. The on-call trauma attending surgeons were asked to wear a RFID badge affixed to their hospital staff ID lanyard during our pilot study. The system captured and recorded the net time between team activation and trauma attending surgeon arrival to the ED. As a comparison, we also continued the historical practice of relying on ED nursing staff documentation in the EHR. Results: Results were captured over a 4-month span. During that period, 57 ED patients required the highest level of team activation. Due to pilot logistics (a limited number of RFID badges prevented all attending surgeons from wearing badges at all times), Trauma faculty was wearing a RFID badge during 46 of 57 activations. There was no RFID data recorded on the other 11 activations (11 for no badge worn, 0 due to system malfunction). Trauma attending arrival was in compliance of the 15-minute window 45 out of the 46 instances (97.8\% compliance rate). Of the 11 activations not recorded via RFID, 8 were documented as in compliance, and 3 were noncompliant in the EHR (1 arrival >15 minutes, 2 missing any EHR documentation; 72.7\% compliance rate). Out of all 57 activations, 5 lacked EHR documentation. Within that subset, the RFID system documented compliance in 4 cases. One activation lacked EHR and RFID documentation. Conclusions: Triangulating trauma faculty location in the ED using RFID beacons is a cost-effective, sustainable system for monitoring arrival time compliance with ACS requirements. An automated system such as our RFID program ensures that our trauma faculty meets ACS regulatory standards for a Level 1 Trauma Center. The system allows ED nursing staff to eliminate an EHR documentation step during critical initial moments in the ED. Internal review of our pilot has justified a full-scale roll-out of our RFID program to trauma faculty. ", doi="10.2196/iproc.8469", url="http://www.iproc.org/2017/1/e31/" } @Article{info:doi/10.2196/iproc.8708, author="Reilly, Erin and Petrakis, Ann Beth and Pigeon, Wilfred and Kuhn, Eric and McInnes, Keith and Owen, Jason and Wiener, Renda and Quigley, S. Karen", title="Detecting the Undiagnosed: Findings on Sleep Apnea Identification in Veterans With Insomnia Using at-Home Sleep Monitor Technology", journal="iproc", year="2017", month="Sep", day="21", volume="3", number="1", pages="e3", abstract="Background: Sleep disorders are a serious national health issue. Insomnia and sleep apnea are the most commonly diagnosed, with serious negative impacts including increased mortality, performance problems, accidents, and health-care utilization. Given a high level of apnea in persons with insomnia (29\%), the incorporation of objective measures of sleep for at-home sleep monitoring for clinical trials may assist in potential sleep apnea detection and treatment for persons with insomnia. This may be particularly important for military personnel, as a 372\% increase in insomnia encounters and a 517\% increase in apnea encounters was recently reported for this population. Objective: The primary goal of this pilot trial was to assess usability and feasibility of mobile health information technologies (HITs) designed to reduce insomnia in post-9/11 Veterans. As this pilot focused on insomnia treatment with HITs, veterans with an objective sleep measure indicating moderate to severe sleep apnea were withdrawn. Participants used a home-based sleep monitor (WatchPAT) which has been validated against polysomnography and derives the Apnea-Hypopnea Index (AHI) from arterial tonometry, pulse oximetry and snoring. We report here on the positive screening rate for sleep apnea in our sample of Veterans with insomnia, a secondary but clinically significant finding within this HIT pilot. Methods: Thirty-eight Veterans were enrolled who met criteria for insomnia on the Insomnia Severity Index, with 33 Veterans in total engaging in the first night of sleep monitoring. A WatchPAT device provided screening results based on AHI scores over 1-2 nights of home use. Those with sleep apnea above the mild range, i.e., AHI > 15 (moderate or severe), were withdrawn from the trial and referred for further assessment. Results: Of the 33 veterans who completed the first night of sleep monitoring at home, a total of eighteen (54.5\%) were identified as having moderate to severe sleep apnea as indicated through WatchPAT measurement. Demographic predictors of apnea were also explored, as apnea rates increase with age and occur more frequently in higher weight individuals. Results were unexpected given the mean age of the final sample (43.8 years, SD = 11.3), as age did not differ between those with no/mild apnea vs. moderate/severe apnea (t (31) = 0.89, ns). However, those with moderate/severe apnea had a significantly higher body mass index (BMI; 30.7, SD = 4.5 vs. 26.8, SD = 2.9; t (31) = 2.88, P<.01). Conclusions: The pilot demonstrated a higher-than-expected positive screen rate for apnea in post-9/11 Veterans. The high co-occurrence of sleep apnea and insomnia in these Veterans suggests the need to conduct comprehensive clinical sleep assessments for Veterans reporting chronic insomnia since apnea may blunt the effectiveness of insomnia interventions. Sleep apnea is treatable and successful treatment can enhance overall health and quality of life. Given the persistence of insomnia in patients treated for sleep apnea, clinicians should also re-assess for insomnia following apnea treatment to determine whether insomnia has resolved. The use of at-home sleep monitors may thus provide a mobile, wearable, and usable at-home sleep monitors for such assessment and treatment. ", doi="10.2196/iproc.8708", url="http://www.iproc.org/2017/1/e3/" }