Cell Phone Use in Health Care Role in DoD Stability Operations

Cell Phone Use in Health CareRole in DoD Stability Operations COL Ron Poropatich, MD TATRC Deputy Director US Army Medical Research & Materiel Command Fort Detrick, MD & Office of the US Army Surgeon General Medical Informatics Consultant 17 August 2008

Disclaimer: "The views and opinions expressed in this presentation are those of the author and do not reflect official policy or position of the Department of the Army, Department of Defense or the U.S. Government."

Cell Phones in Health Care Topics • Background – Market forces • Clinical Applications • Army Medical Department (AMEDD) initiatives • US Government initiatives – PEPFAR/USAID • Stability Operations • Conclusions

Cell Phone World Market Background • By FY09 - 3.3 Billion cell phone users (half the world’s population) • CY2008 - the worldwide mobile industry becomes a $1Trillion industry • 0 to $1 Trillion in 20 years: equal to a growth rate of 30% sustained for 20 years (previously unequalled by any other industry at any time in human history) • A 1 percentage point increase in mobile penetration in developing countries is correlated with an increase of 4.7 percent of average per capita income. • Telecommunications Management Group, 2007 • In 2007, worldwide, non-voice services accounted for 19% of total mobile services revenues, and this keeps growing, reaching more than 26% by the end of 2012. Worldwide consumer spending on non-voice mobile services in 2012 will exceed $251 Billion per annum

Cell Phone Applications Clinical consultation Education Research Biosurveillance

Cell Phone Applications CardioNet, a mobile cardiac telemetry technology HealthPia - blood glucose monitor for diabetes patients integrated into a cell phone, enabling diabetes patients to test glucose levels, record results, and then send them to a caregiver using the same device they carry for making phone calls Emerging markets: Implants and cell phones Data gateway and display device providing active, real-time feedback, coaching, and rewards for healthy, compliant behavior. Biotronik in Germany has already released pacemakers that communicate to physicians via a mobile phone Other implants: glucose monitoring, pain management, implanted defibrillators, weight management for the severely obese, and drug delivery

U.S. Army Initiatives Video Cell Phone Reminder System in Patients with Diabetes Mellitus WRAMC Endocrinology sponsored R&D effort (MAJ Bell/COL Vigersky) Hypothesis: patients with diabetes mellitus who are given a cell phone with a video reminder system will improve glycemic control N=170; prospective, randomized, controlled study 18 month study; $200K funded Impact will be measured by reduction in A1c levels, number of high and low blood sugar fluctuations, mean daily blood glucose levels, amount of time spent in target blood glucose range, and responses to a quality of life questionnaires

U.S. Army Initiatives: Video Cell Phones in Diabetes Mellitus • Study group: will receive a daily 15-second video from their provider reminding them to take their medication and to test their blood sugar and an educational “tip-of-the day.” • Reminders will be personalized and recorded by their provider. • Ninety diabetes educational “tips-of-the-day” will be created and delivered (password protected) on a rotational basis. • Video message will be programmed to be viewed by the patient on a daily basis at a mutually agreeable time. • During the second 6 months, the patients will be followed by their provider at least quarterly with quarterly review of blood glucose and hemoglobin A1c measurement

U.S. Army Initiatives: Cell Phone Use for TBI“Personal Tele-Rehabilitation for mild Traumatic Brain Injury (mTBI) Patients” 9 Goal: To develop an evidence-based support program for mTBI patients & their families that enhances their ability to meet therapy goals while at home utilizing cell phones & data responses uploaded to a secure central server.

Utilize cell phones for TBI care Provide daily prompts & upload results to a web server 3 phase U.S. Army expansion (up to 10,000 patients) Consortium of expertise USAMRMC/TATRC Academic Research Partner Commercial vendor Prior Clinical Uses Diabetes Stroke Rehabilitation Personal Tele-Rehabilitation

U.S. Army Initiatives: Cell Phone Use for TBI • Use the patient’s existing cell phones • Used for frequent patient daily adherence reminders in the form of text messages or data exchanges. • Web-based software platform that sends & receives information between the Case Manager & TBI patients • Designed to augment care provided by the Case Managers • Patient’s self-report data automatically sent back to web server 11

Accomplishments • Technology Platform identified • Secure bidirectional prompts from Case Manager to Patient utilizing web based platform • Concept of Operations developed • Protocol Design Development nearly complete • Outcome Measures identified • Staffing requirements identified • Program Manager and Consultant hired • Project Liaisons (Case Managers at remote sites soon hired) • Consultants (Clinical & Technical identified) • Phase I - Kick off meeting August 5, 2008 12

Phases of Implementation Phase I: 100 Patients Evaluate the impact of using cell phone-based technology on rehabilitative care, on efficiencies of case management and user acceptance of the technology in order to make decisions about large-scale implementation. Phase II: 1000 Patients Phase III: 10,000 Patients

Clinical Outcomes Cell Phone Enabled Rehabilitative Care Patient attends therapy & appointments Patient responds to prompts to get to appointments* Decreased symptoms & complaints; resolution of impairments* Patient has cognitive problems that interfere with getting to TBI-related therapy & medical appointments. Improved life satisfaction* Participation in life roles and activities* Use of cell phone-based tool* Improved carryover in daily life Patient responds to prompts to practice/employ treatment recommendations* Case manager makes real time adjustments to plan of care and/or intervenes Case manager monitors details of care & obtains family perspectives via website* Patient responds to prompts to solicit input from family

Regional View: CBHCO-WI CBHCO-WI Rock Island Arsenal, IL – Ft Lewis PEB (select few DC-PEB) UNCLASSIFIED/FOUO

Regional View: CBHCO-VA CBHCO-VA Virginia Beach, VA - DC-PEB UNCLASSIFIED/FOUO

Regional View: CBHCO-MA CBHCO-MA Concord, MA – DC-PEB UNCLASSIFIED/FOUO

Cell Phone Markets in Africa The number of mobile subscribers in Africa at the end of 2005 was 114M; forecast to rise to 378M by 2011 – 22% growth rate and 265M net additions in 6 years 95% of the subscriber base in Africa is pre-paid, indicating excellent prospects for SMS based services tailored to the African market As Africa relieves its debt burden, continues to liberalize its telecoms markets and open up to further competition and foreign investment, the mobile sector will be a vital component of future growth in a continent with an under developed fixed line telecoms infrastructure

Phones for Health A global public-private partnership to leverage the rapid growth of mobile phone networks in the developing world to help countries deliver health services more effectively. • Country governments • Global health organizations • Mobile phone industry • Leading technology firms • PEPFAR

Phones for Health Partners • The GSM Association representing 700+ mobile operators with 2.4 billion subscribers in 218 countries. • The US Global AIDS Program (PEPFAR) • Motorola • Voxiva – a provider of health information systems in the developing world. • Accenture Development Partnerships – a non-profit division of Accenture supporting development organizations. • MTN – the leading mobile operator in Africa with operations in 21 countries.

Phones for Health Objectives • Develop an integrated set of standard information solutions that support the scale-up of HIV/AIDS, TB, Malaria and other health programs. • Deliver those solutions to countries in a way that is cost-effective, scalable and sustainable. • Help build the foundation for national Health Management Information System (HMIS). • Initial focus on 10 countries in Africa, beginning in Rwanda. • Expansion to other regions in the future.

1.8 billion mobile phones in the developing world. 1 million new phones every day. The explosive spread of mobile phone networks across the developing world has created a unique opportunity to significantly transform how countries can tackle global health challenges. Dr. Howard Zucker, Assistant Director-General, WHO

Mobile Coverage in Africa 90% population coverage by 2010.

$10 million public-private partnership (GSM Association DevelopmentFund, Accenture Development Partners, Motorola, MTN and Voxiva) to leverage technology to connect health systems in 10 PEPFAR-supported countries by 2010 • Phones-for-Health to support treatment for 2 million HIV-infected people, support prevention of 7 million new infections, and support care for 10 million people infected and affected by HIV/AIDS in an accountable and sustainable way. • System allows health workers to report data from the field using their mobile phones, as well as PCs and PDAs. • Data is mapped and analyzed by the system and made immediatelyavailable to health authorities at multiple levels via the web. • The system also supports SMS (text messaging) alerting and notificationand tools for communication and coordination with field staff.

Phones for Health – “Born in Rwanda” HIV/AIDS facilities GSM Coverage

Phone PCs/ Internet PDA/ Smartphone Cell Phone Pay Phone Local Applications Paper Rwanda Pilot - TRACnet

TRACnet • Initial deployment in 2005. • Today, 143 of 148 ART facilities reporting. (>88% using mobiles) • Key Features: • Critical Indicator Tracking • Data Dashboards • National • Regional • District • Facility • ARV Stock Monitoring • Patient Registry • Current activities: • Expansion of patient registry • Expansion to TB, Malaria • Integration with other systems • Support for decentralization • Many lessons learned. UNECA TIGA Award for e-Health.

Qualcomm Wireless Reach Initiative • USAID's public/private partnership agreement with Qualcomm that empowers underserved communities through the use of third generation wireless technologies (3G) • Objective: strengthen economic & social development with a focus on education, governance, healthcare & public safety. • Wireless Reach creates sustainable 3G projects through partnerships with non-governmental organizations, universities, government institutions, development agencies and other private sector companies. • Established in April 2006 – 30 projects in 19 countries • Community Technology and Learning Centers in Vietnam’s 64 provinces - approximately 24,000 students have been trained with the centers' basic IT training program, approx 840 teachers have been tested and trained

Conclusions Cell phone market is large and growing world-wide U.S. Army MEDCOM has active cell phone projects Wireless health care applications are evolving and capable of meeting DoD Stability Operations needs US Government involvement (PEPFAR/USAID) in wireless health care is global – DoD hopes to partner with these other agencies

Questions? Contact: COL Ron Poropatich 301-619-7967 ron.poropatich@amedd.army.mil

Cell Phone Use in Health Care Role in DoD Stability Operations