The history and future of digital health in the field of behavioral medicine

Danielle Arigo, Danielle E. Jake-Schoffman, Kathleen Wolin, Ellen Beckjord, & Eric B. Hekler
J Behav Med (2019) 42: 67.
https://doi.org/10.1007/s10865-018-9966-z

Abstract

Since its earliest days, the field of behavioral medicine has leveraged technology to increase the reach and effectiveness of its interventions. Here, we highlight key areas of opportunity and recommend next steps to further advance intervention development, evaluation, and commercialization with a focus on three technologies: mobile applications (apps), social media, and wearable devices. Ultimately, we argue that future of digital health behavioral science research lies in finding ways to advance more robust academic-industry partnerships. These include academics consciously working towards preparing and training the work force of the twenty first century for digital health, actively working towards advancing methods that can balance the needs for efficiency in industry with the desire for rigor and reproducibility in academia, and the need to advance common practices and procedures that support more ethical practices for promoting healthy behavior.

Here is a portion of the Summary

An unknown landscape of privacy and data security

Another relatively new set of challenges centers around the issues of privacy and data security presented by digital health tools. First, some commercially available technologies that were originally produced for purposes other than promoting healthy behavior (e.g., social media) are now being used to study health behavior and deliver interventions. This poses a variety of potential privacy issues depending on the privacy settings used, including the fact that data from non-participants may inadvertently be viewed and collected, and their rights should also be considered as part of study procedures (Arigo et al., 2018).  Privacy may be of particular concern as apps begin to incorporate additional smartphone technologies such as GPS location tracking and cameras (Nebeker et al., 2015).  Second, for commercial products that were originally designed for health behavior change (e.g., apps), researchers need to carefully read and understand the associated privacy and security agreements, be sure that participants understand these agreements, and include a summary of this information in their applications to ethics review boards.

How Could Commercial Terms of Use and Privacy Policies Undermine Informed Consent in the Age of Mobile Health?

Cynthia E. Schairer, Caryn Kseniya Rubanovich, and Cinnamon S. Bloss
AMA J Ethics. 2018;20(9):E864-872.

Abstract

Granular personal data generated by mobile health (mHealth) technologies coupled with the complexity of mHealth systems creates risks to privacy that are difficult to foresee, understand, and communicate, especially for purposes of informed consent. Moreover, commercial terms of use, to which users are almost always required to agree, depart significantly from standards of informed consent. As data use scandals increasingly surface in the news, the field of mHealth must advocate for user-centered privacy and informed consent practices that motivate patients’ and research participants’ trust. We review the challenges and relevance of informed consent and discuss opportunities for creating new standards for user-centered informed consent processes in the age of mHealth.

The info is here.

An Improved Virtual Hope Box: An App for Suicidal Patients

Principal Investigator: Nigel Bush, Ph.D.
Organization: National Center for Telehealth & Technology

One of the key approaches in treating people who are depressed and thinking about suicide is to help them come up with reasons to go on living, and one of the ways that mental health specialists have traditionally done this is to work with their patients to create a “hope box”—a collection of various items that remind the patients that their lives are meaningful and worth living. The items can be anything from photos of loved ones and certificates of past achievements to lists of future aspirations, CDs of relaxing music, and recordings of loved ones offering inspirations thoughts. The hope box itself can take various forms: a real wooden box or shoe box, a manila envelope, a plastic bag, or anything else that the patient chooses. The patient is asked to keep the hope box nearby and use its contents when it seems hard to go on living.

But it is not always easy to keep such a hope box close at hand. A depressed Veteran or service member might find it inconvenient to take the hope box to work, for example, or might forget to bring it along on a trip. For this reason Nigel Bush and his colleagues at the National Center for Telehealth and Technology have designed a “virtual hope box,” a smartphone app that allows the patient to keep all those reasons for living close by at all times.

The entire app description is here.

Things are looking app

The Economist
Originally posted March 12, 2016

Here is an excerpt:

Constant, wireless-linked monitoring may spare patients much suffering, by spotting incipient signs of their condition deteriorating. It may also spare health providers and insurers many expensive hospital admissions. When Britain’s National Health Service tested the cost-effectiveness of remote support for patients with chronic obstructive pulmonary disease, it found that an electronic tablet paired with sensors measuring vital signs could result in better care and enormous savings, by enabling early intervention. Some m-health products may prove so effective that doctors begin to provide them on prescription.

So far, big drugmakers have been slow to join the m-health revolution, though there are some exceptions. HemMobile by Pfizer, and Beat Bleeds by Baxter, help patients to manage haemophilia. Bayer, the maker of Clarityn, an antihistamine drug, has a popular pollen-forecasting app. GSK, a drug firm with various asthma treatments, offers sufferers the MyAsthma app, to help them manage their condition.

The article is here.

“HIPAA-COMPLIANT” Texting of PHI: The Good. The Bad. The Ugly.

By Alaap Shah and Ali Lakhani
TechHealth Perspectives
Originally published October 14, 2013

Here is an excerpt:

Currently, there is a great deal of uncertainty around whether “HIPAA-compliant” texting of ePHI can be accomplished.  Even greater confusion exists around whether certain texting platforms themselves can be “HIPAA-compliant”.  Before you start to send ePHI via text message, there are a number of issues to consider.

The entire article is here.

F.D.A. to Regulate Some Health Apps

By SABRINA TAVERNISE
The New York Times
Published: September 23, 2013

The Food and Drug Administration said Monday that it would regulate only a small portion of the rapidly expanding universe of mobile health applications, software programs that run on smartphones and tablets and perform the same functions as medical devices.

Agency officials said their goal is to oversee apps that function like medical devices, performing ultrasounds, for example, and that could potentially pose risks to patients. Tens of thousands of health apps have sprung up in recent years, including apps that count steps or calories for fitness and weight loss, but agency officials said they would not regulate those types of apps.

The entire story is here.

Your Smartphone Might Hold Key To Your Medical Records

By Elizabeth Stawicki
Minnesota Public Radio
JUN 17, 2013

It's one of those unhappy holiday surprises -- a visiting family member gets sick. That happened to Dr. Farzad Mostashari last Thanksgiving.

"My dad comes downstairs and he has acute pain in his eye where he had cataract surgery. And I said, 'What's the matter, what's the story?'" recalled Mostashari, who lives in Bethesda, Md. "And he said, 'Well, I think they put the wrong lens in my eye, I'd gone back to the doctor and...'" His father didn't remember exactly what had happened at his last doctor's appointment and the office was closed anyway.

How could a local doctor in Maryland access his dad's medical record in Boston? Through Medicare Blue Button, a computer program that allows patients to download their medical history into a simple text file on their smartphones and personal computers. Then third-party applications that you download help organize this information.

Mostashari certainly knew how to handle his dad's problem. After all, he's the coordinator for health information technology at the U.S. Department of Health and Human Services, and it's his passion and profession to promote electronic health records.

And, he had signed his dad up for Blue Button, which downloads three years of a patient's medical history, as well as the Humetrix iBlueButton, a smartphone app that translates and displays the information in a simple-to-understand way. The file includes names, phone numbers and addresses of physicians as well as diagnoses, lab tests, imaging studies, and medications.

So when Mostashari took his father to a local doctor, his dad was able to hand over his iPhone and say, "Here's my history."

The entire story is here.

Here is a link to Medicare's Blue Button program.

How Does Technology Affect Business Ethics?

By Hans Fredrick
azcentral.com

The more integrated a piece of technology becomes into the way we do business, the more the potential ethical conundrums posed by that technology become apparent. Ethical business practices need to grow and evolve in step with technology. While new devices and advances may make the day-to-day operations of running a business easier, they also create challenges that the ethical businessperson must contend with.

Privacy

Privacy has become a much larger concern in the modern technological age. Business ethicists are still learning and debating how much privacy people are entitled to in the digital age, as are lawmakers. For instance, many employers had taken to the practice of requiring potential employees to provide them with the password to their Facebook pages. This opened up the door to potential privacy issues, not to mention discriminatory hiring practices. In 2012, a law was passed in California to prohibit this particular breach of privacy; but in some jurisdictions, the decision whether or not to ask for this information is still an ethical, rather than a legal matter.

The entire story is here.

Protecting Patient Privacy and Data Security

By Julie K. Taitsman, Christi Macrina Grimm, and Shantanu Agrawal
The New England Journal of Medicine - Perspective
February 27, 2013
DOI: 10.1056/NEJMp1215258

Here is one portion of the article.

STEPS TO PROTECT AND SECURE INFORMATION WHEN USING MOBILE DEVICES*

• Install and enable encryption
• Use a password or other user authentication
• Install and activate wiping, remote disabling, or both to erase data on lost or stolen devices
• Disable and do not install or use file-sharing applications
• Install and enable a firewall to block unauthorized access
• Install and enable security software to protect against malicious applications, viruses, spyware, and  malware-based attacks
• Keep security software up to date
• Research mobile applications before downloading
• Maintain physical control of mobile devices
• Use adequate security to send or receive health information over public Wi-Fi networks
• Delete all stored health information on mobile devices before discarding the devices

* Recommended by the Office of the National Coordinator for Health Information Technology

The entire article is here.

Thanks to Gary Schoener for this article.

iDoctor: Could a Smartphone be the future of Medicine?

The story is here.

More Using Electronics to Track Their Health

By MILT FREUDENHEIM
The New York Times
Published: January 27, 2013

Whether they have chronic ailments like diabetes or just want to watch their weight, Americans are increasingly tracking their health using smartphone applications and other devices that collect personal data automatically, according to health industry researchers.

“The explosion of mobile devices means that more Americans have an opportunity to start tracking health data in an organized way,” said Susannah Fox, an associate director of the Pew Research Center’s Internet and American Life Project, which was to release the national study on Monday. Many of the people surveyed said the experience had changed their overall approach to health.

More than 500 companies were making or developing self-management tools by last fall, up 35 percent from January 2012, said Matthew Holt, co-chairman of Health 2.0, a market intelligence project that keeps a database of health technology companies. Nearly 13,000 health and fitness apps are now available, he said.

The Pew study said 21 percent of people who track their health use some form of technology.

They are people like Steven Jonas of Portland, Ore., who uses an electronic monitor to check his heart rate when he feels stressed. Then he breathes deeply for a few minutes and watches the monitor on his laptop as his heart slows down.

“It’s incredibly effective in a weird way,” he said.

Mr. Jonas said he also used electronic means to track his mood, weight, mental sharpness, sleep and memory.

The entire story is here.

New tools to help providers protect patient data in mobile devices

U.S. Department of Health & Human Services
Press Release
December 12, 2012

Launched by the U.S. Department of Health and Human Services (HHS) today, a new education initiative and set of online tools provide health care providers and organizations practical tips on ways to protect their patients’ protected health information when using mobile devices such as laptops, tablets, and smartphones.

The initiative is called Mobile Devices: Know the RISKS. Take the STEPS. PROTECT and SECURE Health Information and is available at www.HealthIT.gov/mobiledevices.  It offers educational resources such as videos, easy-to-download fact sheets, and posters to promote best ways to safeguard patient health information.

“The use of mobile health technology holds great promise in improving health and health care, but the loss of health information can have a devastating impact on the trust that patients have in their providers.  It’s important that these tools are used correctly,” said Joy Pritts, HHS’ Office of the National Coordinator for Health Information Technology (ONC) chief privacy officer. “Health care providers, administrators and their staffs must create a culture of privacy and security across their organizations to ensure the privacy and security of their patients’ protected health information.”

Despite providers’ increasing use of using mobile technology for clinical use, research has shown  that only 44 percent of survey respondents encrypt their mobile devices.  Mobile device benefits—portability, size, and convenience—present a challenge when it comes to protecting and securing health information.

Along with theft and loss of devices, other risks, such as the inadvertent download of viruses or other malware, are top among reasons for unintentional disclosure of patient data to unauthorized users.

“We know that health care providers care deeply about patient trust and the importance of keeping health information secure and confidential,” said Leon Rodriguez, director of the HHS Office for Civil Rights. “This education effort and new online resource give health care providers common sense tools to help prevent their patients’ health information from falling into the wrong hands.”

For more information, tips, and steps on protecting and securing health information when using a mobile device visit www.HealthIT.gov/mobiledevices.

Mobile medical apps & FDA regulation

The Growth of the Health IT Sector and the Need for More Robust FDA Regulation

By Adam
Nurep
Originally posted on December 21, 2012


Over the last six years, there has been significant growth in the health technology sector (e.g. mobile medical apps), driven by advances in technology and an increase in venture capital (VC) funding. VCs have been lured into the space due to the perception of high returns on investment within shorter timeframes versus their traditional life science funds. The significant growth in this market has driven the need for increased scrutiny from the FDA in how these products should be regulated.

The FDA has the authority to regulate software if it falls within the broad definition of a “device”. It has further segmented medical devices into three classes; Class I, Class II and Class III. Class I devices don’t require FDA regulatory filing (i.e., 510(K), Premarket Approval Application (PMA)) whereas Class II requires 510(K) and Class III devices require a PMA. The class to which a device is assigned determines the type of premarketing submission/application required for FDA clearance, prior to product launch.

While the FDA has had policies in place for many years regarding the regulation of software/computer products, it has historically taken the position not to enforce the regulation unless the product interfaces directly with a medical device. In cases such as these, products have then been subjected to regulation as if they were a medical device. This caused problems for the manufacturers of these devices as there was no structured classification system based on a risk assessment, making it difficult to predict whether a device would end up being a Class I, II or III medical device. Furthermore, the rapid adoption of mobile technology within healthcare meant that there was a pressing need to develop specific guidelines around the regulation of these products also (out of the 14,558 medical apps currently available, only 75 have received clearance from the FDA).

The entire article is here.

U.S. officials launch new strategy to prevent suicide

Reuters
Originally published September 10, 2012

A new nationwide strategy to prevent suicides, especially among U.S. military veterans and younger Americans, is tapping into Facebook, mobile apps and other technologies as part of a community-driven push to report concerns before someone takes his own life.

(cut)

The initiative includes $55.6 million in grant funding for suicide prevention programs.

Suicide is a growing concern and results in the deaths of more than twice as many people on average as homicide, officials said.

On average, about 100 Americans die each day from suicide, officials said. More than 8 million U.S. adults seriously thought about suicide in the last year, according to the Substance Abuse and Mental Health Services Administration.

The entire story is here.

The Flight From Conversation

By Sherry Turkle
The New York Times - Opinion
The Sunday Review
Originally published April 21, 2012

WE live in a technological universe in which we are always communicating. And yet we have sacrificed conversation for mere connection.

At home, families sit together, texting and reading e-mail. At work executives text during board meetings. We text (and shop and go on Facebook) during classes and when we’re on dates. My students tell me about an important new skill: it involves maintaining eye contact with someone while you text someone else; it’s hard, but it can be done.

Over the past 15 years, I’ve studied technologies of mobile connection and talked to hundreds of people of all ages and circumstances about their plugged-in lives. I’ve learned that the little devices most of us carry around are so powerful that they change not only what we do, but also who we are.

We’ve become accustomed to a new way of being “alone together.” Technology-enabled, we are able to be with one another, and also elsewhere, connected to wherever we want to be. We want to customize our lives. We want to move in and out of where we are because the thing we value most is control over where we focus our attention. We have gotten used to the idea of being in a tribe of one, loyal to our own party.

The entire is here.

Thanks to Lou Moskowitz for this story.

This story has implications for face-to-face psychotherapy as well as online therapy.

Doctors' Smartphones And iPads May Be Distracting

By Jenny Gold
Kaiser Health News
This story was produced in collaboration with 
Originally published on March 26, 2012

Dr. Henry Feldman is a mobile technology evangelist. He struts boldly around Beth Israel Deaconess Medical Center, where he works as a hospitalist and programmer, armed with an iPhone and iPad. His nickname is the iDoctor.

Mobile technology, he argues, has made him a better, faster physician. "It lets me do everything I could do if I was sitting at my desktop at the patient's bedside, and actually some things I couldn't easily do," he explains enthusiastically. That includes showing patients impressive new animated apps, diagrams, medical records and even photos from their own surgeries as they recover. 

Beth Israel, a teaching hospital for Harvard Medical School, is one of the most technically advanced hospitals in the country, especially when it comes to mobile technology.

But not everyone at the hospital is quite as gung-ho as Feldman. Recently, Dr. John Halamka, the hospital's chief information officer who helped usher Beth Israel into the electronic world, has been issuing a warning: mobile technology also has a serious downside—it may distract doctors from patient care.

The entire story is here.

mHealth: Remote Patient Monitoring Is On The Rise, With Smartphones Leading The Way

By Rip Empson

Tech Crunch

Originally published February 8, 2012

Last month, we took a look at someof the ways mobile technology is transforming the health industry. While there are many factors affecting this transformation, like artificial intelligence, big data, 3-D printing, social health networks, and remote communications, to name a few (check out Josh’s post on this here), unsurprisingly, change is coming at the hands of the growing ubiquity of cell phones, smartphones, and mobile devices.

Early last year, PEW Researchwas already reporting that 17 percent of mobile phone users were using their devices to look up health and medical information, and Juniperrecently estimated that 44 million health apps were downloaded in 2011.

In turn, the amount and availability of health data is exploding in tandem with the growing adoption of health and medical apps and devices, thanks to the increasingly wearable and user-friendly devices that use smart sensors to capture and transmit a variety biometric data. Electronic medical records (EMRs) are being made available on mobile devices — even KaiserPermanente is getting in on the digital revolution.

The mHealth industry is growing fast. According to Research2guidance‘s calculations, the size of the mHealth app market will nearly double in 2012 to $1.3 billion, up from $718 million in 2011. (I discussed the volatility of these statistics, the still-changing definitions of mHealth and mHealth technology, and conflictingreporting on these numbers here.)

While these numbers can sometimes be misleading, the mHealth sector is not only going to continue to expand, its profitability is going to skyrocket. This is because, in juxtaposition with the $7 trillion global healthcare market, the mHealth market remains incipient. Healthcare companies, startups, and beyond are just beginning to tap into the potential of mobile technology, both in terms of quantified self devices, which bring healthcare in the clinic home, the mobility of data and communication channels. Companies are beginning to spend more and more on research and development, the big kahunas of the medical world are starting to release real, functional mobile apps, and consumer-facing medical devices are just starting to see real market penetration.

The entire information is here.