Interactive Health Communications (their present and future)

It wasn't long ago that cell phones were considered innovative and that personal computers were the center of an individual's access to information and communication technologies. More recently, the field has grown so much that that it has become a major focus of research and development. As a result one of the most respected journals in the health systems research field is the Journal of Medical Internet Research. We now can be confident that computers can improve quality of life and some data suggests it can reduce the costs of care and improve clinical outcomes.

The capability of smart phones continues to increase. Features such as GPS, accelerometers, two way cameras, light sensors, fuzzy matching, optical object recognition and sound are continuously improving. Further more, add-ons make it possible for a smart phone to be able to read bar codes and RFID chips. And the increasing brute strength of smart phones, tablets, and data services will reach the point that they function as fast as one's home computer.

Recently health and healthcare have become a prominent focus for developers of apps for smart phones. Specifically, more and more apps are being produced to help people deal with their health needs. By November 2011 nearly 13,000 health apps were available for smart phones, many related to substance abuse and behavioral health more generally.

Of course, quantity rarely equals quality. And because of the wide variation in quality, it has become hard to differentiate good from bad, useful from harmful. The old Latin expression caveat emptor is very important in this context where they may be a lot of good stuff out there but it is very hard to find. In fact we completed a randomized clinical trial a few years ago where we compared breast cancer patients with access to the Internet to patients without it. We found that if anything, Internet users did more poorly than those who had no such access.¹

In a sense, it makes sense. When you go to the Internet, you're faced with myriads of websites that offer conflicting information and operate in very different ways. Feelings of frustration, fear, anger and uncertainty are close to the surface. Smartphone and tablet apps can bring on the same feelings.

Computers (including tablets and smartphones) can be frustrating in and of themselves. But here, unlike the Internet, there is hope for the future. As those of you who know me already realize, I am older than dirt. Three years ago I had a heart transplant. The anti-rejection drugs that I take have had two side effects. First I am getting cataracts from the Prednisone. Second, my hands tremble from the Prograf. Believe me I am very happy to have these minor inconveniences rather than the alternative. But they do have implications for smart phone use. First, it is hard to see the small screen and second, it is hard to type in messages. Of course if you are young, you probably don’t have these problems, but many of us do.

The exciting thing is that the world is changing. Smartphones are very close to being completely navigable by voice. Apple's Siri is a recent example of how close we are. And text-to-voice lets users listen to content rather than just ready it. And sensors (many already built into the smart phone – like GPS, accelerometers, cameras, etc.) now allow us to measure the quality of sleep by putting the phone under the mattress, identify if you are approaching a favorite bar with GPS, measure your heart rate with the camera, etc. Right now they are pretty accurate but in the near future they will be very good and just the beginning for what is to come.

Moreover, research is already demonstrating the power of computer apps. It is pretty clear that computer programs (including some apps) can improve quality of life, change behavior, improve coping, act as motivators and can provide emotional and instrumental support². What is less clear is how to distinguish the great programs from others, because no matter what problem you have, there really is an app for that.

So what can I tell you? Well, start out by being skeptical. Assume that most of the stuff you find is a gimmick, and commit yourself to being very careful before you buy. I just purchased an app to take my heart rate and blood pressure. I was excited because I had heard that such devices do exist. The description sounded good and it had a four-star rating out of five. So I downloaded it for just 99¢. It seemed like my only way to try it out. What the description did not say was that you used your standard way to collect the data (your home blood pressure monitor or by counting). So all it really does is store and display information that I put into the phone. What it does, it does well. But it was not what I had expected. I should have been skeptical when only 20 people had reviewed it. I should have read the description more carefully. I should have tried to find out whether the system had been tested. I should have read the reviews instead of just looking at the average rating score. Caveat emptor, after all.

But having said that, apps are not going away, thank heavens. The good apps and the more sophisticated programs like CHESS³ and TES⁴ , have been carefully reviewed and proven to be effective. In fact we currently have a research consortium where agencies are using A-CHESS for different purposes and jointly finding best practices for effectively implementing the technology. And there are many more great programs to come that will revolutionize our fields. We will know so much about a person and we will know it when it happens, not three weeks later. We will be able to intervene just in time. And the technology will be able to deliver care anytime and anywhere, with a consistently high degree of quality.

But one more caveat. We won’t be able to just take these innovations and plop them down in the middle of an existing treatment system. Agencies who have tried distance counseling know that the way you counsel when a person is in the same room with you is very different than if you are doing it by Skype or some other video communication system. Retraining may be needed. Incentives, policies and job descriptions may need to change. The scary part of this is that it may actually be easier to start from scratch than to get organizations to change. And there in lies the challenge. Do we want to be the buggy whip manufacturers of old or do we have the energy to lead the revolution?

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1. Gustafson, D.H., Hawkins, R., McTavish, F., Pingree, S., Chen, W.C., Volrathongchai, K., Stengle, W., Stewart, J.A., & Serlin, R.C., (2008). Internet-based interactive support for cancer patients: Are integrated systems better? Journal of Communication, 58(2), 238-257. PMCID: PMC3144782
2. Gustafson, D.H., Boyle, M.G., Shaw, B.R., Isham, A., McTavish, F., Richards, S., Schubert, C., Levy, M., & Johnson, K. (2011). An e-Health solution for people with alcohol problems. Alcohol Research & Health, 33(4), 327-337. NIHMSID: NIHMS316851
3. Gustafson, D.H., Shaw, B.R., Isham, A., Baker, T., Boyle, M.G., & Levy, M. (2011). Explicating an evidence-based, theoretically informed, mobile technology-based system to improve outcomes for people in recovery for alcohol dependence. Substance Use and Misuse, 46(1), 96-111. PMCID: PMC3179272
4. Marsch, L. A., Grabinski, M. J., Bickel, W. K., Desrosiers, A., Guarino, H., Muehlbach, B., Solhkhah, R., Talfique, S., & Acosta, M. (2011). Computer-assisted HIV prevention for youth with substance use disorders. In Special Issue on Technology and Substance Use Disorders (Guest Editor: Marsch, L. A.) Substance Use and Misuse, 46, 46-56