33. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
CHALLENGES OF MOBILE HEALTH:
RESEARCH METHODOLOGIES ARE OUTDATED
• Way too many apps, pilots
• Lack of standardization
• Lack of sound methodology
• Lack of data interoperability & systems
integration
Tomlinsonetal.,2013
40. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
MHIMSS EVALUATION METHODS
http://www.mhimss.org/sites/default/files/resource-media/pdf/HIMSSguidetoappusabilityv1mHIMSS.pdf
Selecting a Mobile App: Evaluating the Usability of
Medical Applications
mHIMSS App Usability Work Group
July 2012
Table 2 – Usability Principle Attribute ChecklistUsability
Principle
Mobile Design
Tenet
Example attributes of a “usable” app
Let data scream Only information, visual elements and functionalitynecessary to core tasks and decisions are included.Important information stands out, and function options
are easy to understand. The focus is the data.The app has a clear, clean, uncluttered screen design.Speak my sign
What interface?
Screen metaphors are familiar to everyday life, orcommonly expected computer experiences for theclinician.
Workflows match the clinical practice needs.The app is intuitive and easy to learn; minimal, if any,
training is required.
Iconography and symbols speak “naturally.”
Grid it
Graphic design and layout have the same look and feel,
consistent placement of screen elements (e.g., gutters,
columns, margins and captions).Terminology and data entry fields are used consistently.
Understanding how one screen works helps youunderstand how other screens work
Date your users
Simplicity
Naturalness
Consistency
44. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
DATA & PRIVACY OVERVIEW BY GLENN ET AL.
“Predictive modeling, referred to
by the advertising community as
behavioral targeting, is used to
bring specific advertisements to
online users based on their
perceived interests… Target
predicted that a customer was
pregnant due to purchasing
patterns…”
CurrPsychiatryRep(2014)16:494DOI10.1007/s11920-014-0494-4
45. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
DATA & PRIVACY OVERVIEW BY GLENN ET AL.
“This incident also highlighted
that personal health
information can be created by
combining seemingly
innocuous data, and that a
predictive model outside of
HIPAA protection can cause
harm whether or not it is
accurate.”
— Tasha Glenn, Scott Monteith
CurrPsychiatryRep(2014)16:494DOI10.1007/s11920-014-0494-4
47. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
NATIONAL HEALTH SERVICE — APP STORE RISKS
Of 27 apps [using online API’s], 16 (59 %, n =
16/27) allowed unencrypted access. Two apps
had critical vulnerabilities which permitted
access to user information, including
information belonging to other users, without
authorization.
Huckvaleetal.BMCMedicine(2015)13:214DOI10.1186/s12916-015-0444-y
48. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
NATIONAL HEALTH SERVICE — APP STORE RISKS
Half of apps (50 %, n = 35/70) included strong
identifiers in transmitted information. Two-
thirds of these (66 %, n = 23/35, 29 % of all
apps) sent identifying information without
encryption, including email addresses (n = 5),
account login details (n = 5), full name (n=2) or
date of birth (n=2).
Huckvaleetal.BMCMedicine(2015)13:214DOI10.1186/s12916-015-0444-y
49. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
NATIONAL HEALTH SERVICE — APP STORE RISKS
[Of the apps with privacy policies,] for a small
number (4 %, n = 2/49) information handling was
completely consistent with commitments made by
the policy. However, while no apps transmitted
information where a specific commitment had
been made not to, four-fifths either collected (82
%, n = 42/49) or transmitted (78 %, n = 38/49) one
or more data items not addressed by a policy.
Huckvaleetal.BMCMedicine(2015)13:214DOI10.1186/s12916-015-0444-y
50. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
THREE KEYS TO INCORPORATING APPS
1 Use reputable institutions & verified
developers.
2 Try an app yourself first. If an average
person can use it — prescribe it.
3 Informed consent on security, privacy,
and lack of testing is key.
53. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE?
PATIENTS WILL MANAGE THEIR OWN HEALTH.
“People with psychotic
disorders were able and
willing to use e–mental
health services. Results
suggest that e–mental
health services are at least
as effective as usual care or
nontechnological
approaches.”
LianvanderKrieke,M.Sc.,M.A.LexWunderink,M.D.,Ph.D.AndoC.
Emerencia,M.Sc.PeterdeJonge,Ph.D.SjoerdSytema,Ph.D.E–
MentalHealthSelf-ManagementforPsychoticDisorders:Stateofthe
ArtandFuturePerspectives.”PsychiatricServices65:33–49,2014;
doi:10.1176/appi.ps.201300050
54. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
PEOPLE CAN’T AFFORD MENTAL HEALTH
“According to SAMHSA’s 2014
National Survey on Drug Use
and Health (NSDUH), 43.6
million people had a mental
illness in the past year. But
fewer than half received
treatment. That’s one in five
Americans over the age of 18.”
— Paolo del Vecchio, M.S.W.,
Director, Center for Mental
Health Services, Substance
Abuse and Mental Health
Services Administration
http://blog.samhsa.gov/2015/10/05/accelerating-access-to-mental-health-treatment/
57. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE?
PATIENTS WILL MANAGE THEIR OWN HEALTH.
JeanaHFrost,PhD; MichaelPMassagli,PhD.”SocialUsesofPersonalHealthInformationWithinPatientsLikeMe,anOnlinePatient
Community:WhatCanHappenWhenPatientsHaveAccesstoOneAnother’sData”http://www.jmir.org/2008/3/e15/.
59. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE?
OUTPATIENT SURVEY
Harvard
LSU
New Orleans
UC Davis
Sacramento Cty
U Wisconsin,
Madison
State n=106
Private n=108
County n=56
County n=50
36.2 y
39.6 y
44.7 y
43.9 y
MEAN AGE
60. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
WHY SHOULD WE CARE?
OUTPATIENT SURVEY
Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter
Yellowlees,MDMBBS;MatcheriKeshavan,MD.
61. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
OUTPATIENT SURVEY STATISTICS
Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter
Yellowlees,MDMBBS;MatcheriKeshavan,MD.
33
25
6
37
53
17
13
17
62
9
17
13
72
16
5
8
0
25
50
75
100
State
C
ounty
1
C
ounty
2
Private
ClinicType
Percentage
OwnershipandWillingness
HasSmartphoneandWil
NoSmartphonebutWillin
HasSmartphonebutUnw
NoSmartphoneandUnw
Has smartphone + Willing
No smartphone + Willing
Has smartphone + Unwilling
No smartphone + Unwilling
state
county 1
county 2
private
63. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
OUTPATIENT SURVEY DISCUSSION
• 58% ownership of smartphones mirrors
national U.S. 58% ownership
• 71.4% psychiatric outpatients are favorable
to the idea of using smartphones for MH
• Age matters: Younger use >> older
• Socioeconomic status matters:
Private insurance >> public patients
Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter
Yellowlees,MDMBBS;MatcheriKeshavan,MD.
64. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
OUTPATIENT SURVEY LIMITATIONS
• Use of app hypothetical; not verified practice
• Selection bias what about non-volunteers?
• No individual diagnoses
• No control for differences in smartphone
ownership rates in each community
Pendingpublication.JohnTorous,MD;StevenChan,MDMBA;MarieTan,MD;JakeBehrens,MD;IanMathew,BS;LadsonHinton,MD;Peter
Yellowlees,MDMBBS;MatcheriKeshavan,MD.
65. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
DIGITAL HEALTH OVERVIEW
104 M in the U.S. own smartphones
Mobile healthcare & medical app downloads
reach 44 M in 2012, rising to 142 M in 2016
McKinsey projects opportunities in global
mHealth to be $60 B
19% of smartphone users have health apps
http://rockhealth.com/healthcare-and-digital-health-facts/
67. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
Technology will
change the way
we practice
mental health.
SPEECH ANALYSIS
EYE & FACE RECO
SMART CLOTHING
INGESTIBLES
Tasha Glenn, Scott Monteith.” New Measures of Mental
State and Behavior Based on Data Collected From
Sensors, Smartphones, and the Internet” Curr Psychiatry
Rep (2014) 16:523 DOI 10.1007/s11920-014-0523-3
WEARABLE DEVICES
68. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
ADVANTAGES OF MOBILE HEALTH:
MOBILE
• Just-in-time context-aware interventions
• Portable location-independence
• Low-power low- to middle-income
countries with less-established infrastructure
• Lower cost than traditional desktop
computers
Hiltyetal.2013,Harrisonetal.2011,Klasnja&Pratt,2012;WHOGlobalObservatoryforeHealthandWHO,2011
95. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
ADVANTAGES OF MOBILE HEALTH:
CAN BE MORE ENGAGING.
CurrPsychiatryRep.2014Dec;16(12):520.doi:
10.1007/s11920-014-0520-6.
Theuseofelectronicgamesintherapy:areview
withclinicalimplications.Horne-MoyerHL1,
MoyerBH,MesserDC,MesserES.
“The use of
electronic games
in therapy: a
review with clinical
implications”
131. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
REAL-TIME LANGUAGE INTERPRETATION:
WHY IS LANGUAGE IMPORTANT?
• In 2002, approx. 6 million immigrant adults aged
18-64 did not speak English well. More than 2.5
million did not speak English at all.
• Professionally-trained interpreters are often not
available in community-based practices.
• Failure to use interpreters
– hospital admission rates
– use of testing
– poorer patient comprehension
– misdiagnosis and improper treatment
140. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
ULTIMATE GOAL
• Analyze language as data.
• Create new clinical processes for in-
person care and telemedicine.
• Create a better standard of care with
improved interpreting, more
efficiently, and less expensively.
141. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
PRELIMINARY TRANSLATION TESTS
English
Tell me about your girlfriends.
They were animals.
Pick one, and tell me about her.
I met a woman last year; she was a stray cat.
Why do you say she was a stray cat?
She had no connections.
What was it that you were attracted to?
Her body.
Okay. What kicked in about her personality later?
What do you mean?
If I met her, what would I notice about her?
It's tough to answer. Her attitude.
How was that?
It was good.
What do you think you'll be doing in five years,
and what would you like to be doing?
I'll probably be dead. I'd like to be a physician.
From Daniel J Carlat’s The Psychiatric Interview
2nd Edition.“Obtaining the Social and
Developmental History." pp.104-105
142. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
PRELIMINARY TRANSLATION TESTS
English
Tell me about your girlfriends.
They were animals.
Pick one, and tell me about her.
I met a woman last year; she was a stray cat.
Why do you say she was a stray cat?
She had no connections.
What was it that you were attracted to?
Her body.
Okay. What kicked in about her personality later?
What do you mean?
If I met her, what would I notice about her?
It's tough to answer. Her attitude.
How was that?
It was good.
What do you think you'll be doing in five years,
and what would you like to be doing?
I'll probably be dead. I'd like to be a physician.
Bing Translator EN ES EN
Tell me about your friends. C
They were animals.
Choose one and tell me about it. P
I met a woman last year; It was a stray cat. P
Why you say that it was a stray cat? P
It had no connection. P
What was it that attracted you?
Your body. P, C
It is ok. He kicked him later about his personality? N, P
What do you mean?
If I knew her, would count on it it? N, P
It is difficult to answer. His attitude. P
How was that?
It was good.
What do you think to be doing in five years, and what
would you like to do?
I will probably be dead. I'd like to be a doctor.
Odd pronouns
Non-sensical
Critical error
143. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
PRELIMINARY TRANSLATION TESTS
English
Do you have any thoughts about what
might have prompted your wife to call
the ambulance?
It sounds like you’ve been very sad
since your mother’s death, and that
her death after so many years of
suffering has also felt like a relief.
You look very sad.
I know you have much to tell me, but I
need to shift to getting some basic
information.
I see you’ve thought a lot about the
previous treatment team, but could
you tell me when you had that last
hospitalization?
From John Barnhill’s “Chapter 1. The Psychiatric Interview
and Mental Status Examination”. The American Psychiatric
Publishing Textbook of Psychiatry . 6th Edition.
144. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
PRELIMINARY TRANSLATION TESTS
English
Do you have any thoughts about what
might have prompted your wife to call
the ambulance?
It sounds like you’ve been very sad
since your mother’s death, and that
her death after so many years of
suffering has also felt like a relief.
You look very sad.
I know you have much to tell me, but I
need to shift to getting some basic
information.
I see you’ve thought a lot about the
previous treatment team, but could
you tell me when you had that last
hospitalization?
You have any idea about what could
be done for his wife to call the
ambulance? C
It seems that you've been very sad
since the death of his mother, and that
he also felt his death after so many
years of suffering as a relief. C
You feel very sad.
I know that you have much to say, but
I need to change to get some basic
information.
I see that you thought much about
pretreatment equipment, but could
you tell me when was that last
hospitalization? N
Bing Translator EN ES EN
Non-sensical
Critical error
150. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
ASYNCHRONOUS TELEPSYCHIATRY WORKFLOW
PRIMARY CARE
PROVIDER
PATIENT-CLINICIAN
“VIRTUAL VISIT”
PSYCHIATRIST
VIDEO
CONSULT
NOTE
STORE ON
VIDEO FILES
STEP 1:
Provider refers patient
to telepsychiatry.
STEP 5:
We measure satisfaction,
symptoms & outcomes
every 6 months.
STEP 2:
A video of the patient
interview is recorded
STEP 3:
Video & history sent securely
to consulting psychiatrist.
STEP 4:
The specialist’s consult &
recommendations are sent
to primary care provider.
151. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
ATP SUMMARY OF FINDINGS
Diagnostically reliable across
differing language groups
with translation
Not suggested for therapy
Can be used for monitoring
treatment progress
Easier management/admin/
scheduling
Improved communication
between patient and
reporting provider
152. @StevenChanMD @UCDavisHealth #DigitalMentalHealth
THE VCC TEAM
• Peter Yellowlees MD
• Alberto Odor MD
• Lorin Scher MD
• Michelle Parish MA
• Steven Chan MD
• Breanne Harris BA
• Glen Xiong MD
• Robert McCarron MD
• Andres Sciolla MD
• Anna-Maria Iosif PhD
• Paul Leigh PhD
• Bill Brady MD and Auburn
Clinic staff – UCD PCN
• Scott MacDonald MD and J St
Clinic staff – UCD
• Communicare FQHC staff
• CHT technical team – George
Wu, Kalim Simon
• EMR Epic team – Mike Minear
and Hien Nguyen MD
• Psychiatry Outpatient Clinic –
Becky Mackey
• Don Hilty MD USC
• Jay Shore MD U Colorado
