Asthma patients are bringing their condition under control, increasing their lung function and decreasing the frequency of asthma attacks without doctor visits, thanks to a study on app-oriented treatment by Jennifer Mammen, University of Rhode Island College of Nursing assistant professor.
The Technology Enabled Asthma Management Systems, which Mammen created, uses patients’ smartphones to treat their condition anywhere at any time, making it easier and more convenient for them, increasing the level of care they receive.
The app asks patients a series of simple questions about their condition each day: Did asthma limit your activity in the past 24 hours? Did you wake up because of your asthma last night? Patients also record their lung function using a digital peak flow meter provided to them. The patient’s symptoms are automatically entered into a “smart” flowsheet, which assesses the patient’s condition based on standard guidelines, calculates the asthma severity and recommends proper therapy. A nurse analyzes the information and provides feedback to the patient through screen-sharing and regular telehealth video chats.
The study’s results have drawn national attention, earning an outstanding achievement award from the American Thoracic Society for Top Nursing Abstract. Mammen is continuing to refine the system, currently working with a group of 30 asthma patients, with plans to expand to a full-scale clinical trial soon.
PBN: Please explain how the idea for this app occurred to you. Was it the first solution you thought of for managing asthma-patient care?
MAMMEN: I became interested in asthma self-management because so many people with asthma are chronically uncontrolled, even though this is a highly controllable disease. The medical community has been working on it for more than 50 years, and it isn’t getting much better. Until recently, most research was focused on what people weren’t doing – not taking medications regularly, not reporting symptoms accurately – and on developing interventions to increase compliance or adherence to treatment. There wasn’t a lot of information about what people actually were doing to manage their asthma, and why they chose to do it.
I started to dig into how people thought about asthma self-management. We found that people aren’t motivated by medical goals, and don’t always see the point of doing it the recommended way; they just want to minimize the impact asthma has on their lives. Basically, if the burden of treating asthma was greater than the perceived benefit, people weren’t going to do it. If we want to change things, we have to shift the balance of benefits and burdens for people to make it easier and personally meaningful for people to manage their health well.
For example, if patients only get a 10-15 minute visit with their health care provider and they have to cover five problems in that time, there isn’t much time to spend on asthma. I can’t change the length of a visit, so we had to find a different way to get people the time they needed without a lot of travel, missing work, or sitting in a waiting room. That meant a whole new approach to delivering primary asthma care.
We basically latched on to technology as a means to address many of the major barriers to health care. If you can’t get to me because you don’t have a car and work for minimum wage Monday through Friday, well, I can get to you on Saturday using your smartphone.
PBN: Your URI bio notes you worked on the University of Rochester EMR build team and were a certified Epic EMR builder. Can you give us more detail on your technical background and how that played into the development of this app?
MAMMEN: Actually, I’m still on the build team at the University of Rochester, as this is an ongoing collaboration with UR and URI. When I started developing the TEAMS program, the first problem was a lack of build resources. We had a great idea but no way to develop it. The medical record is a massive, complicated system and there simply aren’t enough technical people available to do everything we want to do. The only way to get the project off the ground was to hire my own builder. However, at the time, I was a post doc with no funding. So, I got certified and built it myself.
IT [information technology] training through Epic was a real eye-opener and the best decision I could have made. It made me realize all the things we could do that we weren’t tapping into because no one could see both sides. Clinicians, researchers, and IT builders come from very different worlds and don’t speak the same language, so a lot gets lost in translation. I’m very fortunate that I straddle all three worlds. Because of that, we’ve really been able to push the boundaries and start doing things that no one realized was possible.
PBN: The story of the bipolar patient who also suffered from asthma, [the providers were] perpetually focused on the former instead of the latter, indicates a counterintuitive theme where too much personal interaction negatively affects care. What are your thoughts about that?
MAMMEN: In this case she didn’t feel she was benefiting by her care, so she stopped engaging. It actually isn’t uncommon to get asthma and anxiety/panic mixed up. She didn’t realize her shortness of breath was linked to her asthma and neither did her health care providers. If someone looks like they are panicking and hyperventilating and they have a history of mental illness, then it’s a fairly intuitive leap to think that’s the root of the problem. In her case, she knew so little about her asthma that she couldn’t tell the difference herself and didn’t know to communicate it to her providers. It was a perfect setup for disaster.
We found her through random recruiting calls, and it was only through the process of systematic education and follow-up that we discovered what was going on. Once her asthma improved, she was so encouraged that she went back and began re-engaging with her regular health care providers. She didn’t realize that she could live without being short of breath. A lot of the people we treat assume that having asthma means they are going to have trouble breathing. In fact, being well-controlled means you should have symptoms twice a week or less. Any more than that, and you’re not controlled.
PBN: You mention people with chronic asthma often don’t realize their symptoms can be controlled. Is this something primary care physicians and/or specialists aren’t communicating effectively to their patients?
MAMMEN: Absolutely, yes. We urgently need to change how we assess asthma. Asking, “How has your asthma been?” at a checkup isn’t effective. Our research shows that if symptoms are perceived as normal, patients will tell you their asthma is fine, even if it is clinically grossly uncontrolled. Providers need to ask specific questions [such as], “About how many times a week do you have any symptoms of asthma?” Describe specific symptoms, slow down and give the patient time to think. If providers don’t treat it like it’s important, neither will the patient.
Second, there are national guidelines on asthma that define how much medication to give for different symptom levels, but few providers actually use them. When patients get the wrong dose, they feel like the medication doesn’t work, and don’t stick with it. This program calculates asthma severity and control, along with the guideline recommended step-wise therapy. It generates a full report for the provider with recommendations for medication adjustments and follow-up. We’ve had excellent success with this and are seeing prescribing changes and increased awareness of the guidelines. Basically, we support providers without increasing their work load, which has been central to our success.
Third, we need to change how we educate patients. This is the most challenging, because education takes time. It’s just not realistic to expect that we can adopt a fast-food approach and walk away with high-quality health care. The TEAMS program is compensating for this problem by providing personalized education over multiple visits. We teach our patients about asthma, and we teach them how to advocate for themselves at their health care visits.
All of our materials are designed for smartphone, and teaching is done virtually during telemedicine visits with screen-sharing. It works really well, but it takes time. For most of our patients, it takes about four dedicated visits before they understand what they are doing enough to control their asthma.
PBN: What refinements to the system do you hope to achieve with your current work?
MAMMEN: We’re focusing on ways to streamline the system and make it even more convenient and efficient. We ask patients to answer several questions about their asthma each day; I’m hoping we can reduce that to one or two. We are continuously refining how TEAMS integrates into primary care. There has been a steep learning curve in working with providers as a consulting service, including finding best ways for communicating since everything is done virtually.
I would love to shorten the response time for medication adjustments. The TEAMS nurse doesn’t do the prescribing; we make recommendations to the primary providers. That tends to slow down the process. I want to make prescription changes happen within 24 hours on a consistent basis. This is an instant generation; when we can respond quickly, we prove that we care about what we are doing and that it’s important. It really blows people away.
Lastly, I’d like to see this go bigger. We could be reaching people all over the nation if we had the resources and willing collaborators. I think we could really change the way we do asthma care and make a big difference. Ultimately, I’d like to take the TEAMS approach and plug it into other chronic conditions, [such as] diabetes or hypertension management. There is a lot of opportunity to deliver virtual care that doesn’t require a trip to the doctor’s office.
Rob Borkowski is a PBN staff writer. Email him at Borkowski@PBN.com.