NIH Challenge Grants and mHealth

[Thomas GIannulli MD, MS]

The recent post o this site at NIH Begins Reviews of Record Number of Proposals is interesting and it relates to mHeath to a degree. One of the grants numbered 06-LM-10 is directed towrds a real time point of care data caputre solution, and as such is ideal for a mobile device and appropriate software. I am not sure how many applications related to this grant were filed that included some form of PDA or smartphone, but I would guess quite a few. I worked with an associate to draft a proposal for this grant that utilized an iphone to capture voice and menu data in real-time. As the grant is still under evaluation I am not sure of the outcome but I will post it here when it is available. I encourage others to comment on this topic as well.

[Paul B. Simms]

Thank you for your comment, Dr. Glannulli. Historically, EMR's have been developed by hospitals - entities that have had the resources to fail, then fail again, and ultimately become more successful, when progress is measured in small segments. The shift towards a more patient-centric medical information worldview suggests that the evolution of an EMR should be coupled with a Personal Health Record (PHR).. Such a PHR would be a tool to manage, organize, prioritize and then coach a patient - and his or her family - about the significance of the findings, conclusions, treatments and the lifestyle changes that should (MUST) be implemented to improve health outcomes. Such a strategy would make the patients (and families) the partners in the health care solution. This observation should be a core value in driving the next logical system redesign.

For persuasive technologies to be successful, there will necessarily be a non-physician Health Advocate in the system - an individual whose activities and interests are aligned with patients - and whose skills are sufficently representative to bridge the gap between 20 minute office visits (at maximum) provided quarterly to primary care physicians, with more limited interaction with specialists and the host of managerial problems (and resources) reflected in lifestyle management for patients with and without insurance (or with publicly funded payers Medicaid or Medicare). There are huge differences between middle class, self-actualizing, self-mobilizing families - many of whom have health insurance - and the 15-20% of the population for whom access to health care is "unstable" (a euphamism for "not available").

Hospitals don't practice medicine - physicians do. The nature of the EMR-PHR system development we want to pursue should STRENGTHEN the role of the patient (and family), the primary care physicians, and the specialists - all connected digitally.

Health reform "planets" of this magnitude don't align in this fashion often. The dialogue we should pursue envisions the core values of both a commercial applicability subsystem and a public interest subsystem with access to either/both through a revolving door. Currently, our health care services are practiced in "silos", with the management worried about lost opportunities and market share. Such a dual-focused EMR-PHR development strategy would promote the vision of hundreds of thousands of individuals who have lost their jobs in this economy to continue with access health care - with a history, clinical values and data tracking tool in hand and eligibility digitally accomplished. "One-e App" (funded by the California Healthcare Foundation and the California Endowment) has demonstrated the benefits and savings of digital eligibility for public resources. Medicaid funding was always considered "marginal" funding - much like the uninsured ("unwashed poor") it supported. Had Medicare, our national health insurance for the elderly, obtained federal funding adjusted for inflation, it might be considered "good insurance" today.

Left to their own devices, many families will return to basic strategies of raising their own fruits and vegetables, shifting to more vegetarian diets, promoting alcohol for external uses only, and embracing the notion that food is best consumed with water - which promote better health. Preventing chronic diseases among high-risk individuals is a viable public health objective - working with "assets" in high risk communities like religious and civic organizations. Preventing these chronic diseases requires more effective early diagnosis and more efficient interaction with those who are becoming so afflicted. This is where home monitoring and creating family health care management units represents a very positive design objective.

At the end of the day, these processes are managed by human beings. They come with their fears and biases, their technology gaps and proclivities. Our vision reflects a technology model similar to a toaster. Use without reading the instructions. Consumes electricity only when used. Delivers a consistent value for its dollar. Otherwise sits on the counter, unnoticed. And when the unit breaks, don't fix it - replace it.

Some people who work well with inanimate objectives have difficulties with people. The evolution of the work "geek" carries some sense of this reality. One important element of the iphone systems to capture voice and menu data is to guide the solutions to the presented context, history and culture. These systems are perhaps best described by physicians, nurses or similar Health Advocates.

My real fear is that three years from now, when the GAO begins to evaluate the outcome of the infusion of this level of funding into HIT and electronic medical records, we will not have developed the optimum cluster of pathways for EMR system development. By pursuing the individualism of a thousand different options, as reflected in NIH's solicitation list promulgated in February 2009, the right answer may elude us and this opportunity will be lost.

Consuming a whale of this size still requires eating one bite at a time.

Paul B. Simms

[Gerry Higgins]

Good luck, I hope you get funded. I decided not to submit, and now the director's office said they had received about 32,000 applications for a maximum of 500 funded projects.