What do mHealth, eHealth and behavioral science mean for the future of healthcare?

Dr. Audie Atienza focuses on the intersection of behavioral science, data and healthcare apps.

We’re living through one of the most dynamic periods in healthcare in our collective history. Earlier this year, Dr. Farzad Mostashari, the national coordinator of health IT, highlighted how the web, data and epatients are poised to revolutionize healthcare. The Internet is shaping healthcare in many ways, from the quantified self movement to participatory medicine, and even through the threat of a new “data divide” driven by unequal access to information, algorithmic and processing power.

Dr. Audie AtienzaInto this heady mix, add the mobile computing revolution, where smart devices rest in the pockets of hundreds of millions of citizens, collecting data and providing access to medical information. There’s also the rapidly expanding universe of healthcare apps that promise to revolutionize how many services are created, distributed and delivered.

This month, I had the opportunity to discuss some of these trends with Dr. Audie Atienza (@AudieAtienza), a researcher who focuses on behavioral science and healthcare. Our interview, lightly edited for content and clarity, follows.

We first met when you were a senior health technology adviser at the U.S. Department of Health and Human Services (HHS). What do you do now?

Audie Atienza: Working with Todd Park at the Department of Health and Human Services (HHS) was a distinct privilege and an honor. I learned a great deal working at HHS with Todd. I am now at the new Science of Research and Technology Branch of the National Cancer Institute, National Institutes of Health.  My title is Behavioral Scientist and Health Scientist Administrator. In a typical week, I attend health-technology-related conferences and meetings, work with colleagues across HHS and the federal government on health-technology-related initiatives, discuss funding opportunities with extramural researchers, and engage in scientific research related to health technology and/or cancer control.

How well did your education prepare you for your work?

Audie Atienza: My undergraduate, graduate and post-doctoral education has provided me with the critical thinking skills and knowledge that is required of a health researcher. My interest in health technology actually started when I was a Fellow at Stanford University, where I was gathering data on cardiovascular disease risk factors using paper and pencil diaries.  Using paper and pencil measures seemed so inefficient. Study participants sometimes forgot to complete the diaries or had incomplete entries — and sometimes the handwriting was difficult to decipher.  So, my mentor, Dr. Abby King, and I collaborated with Dr. BJ Fogg (also at Stanford) and we “went digital” with the cardiovascular disease risk factor assessments. (We used “state of the art” PDAs at the time.)  This fortuitous collaboration and the “there has to be a better way to do this” idea launched me into the field of electronic and mobile health.

What does “eHealth” mean now?

Audie Atienza: After my postdoctoral fellowship at Stanford, I accepted a position at the National Cancer Institute (NCI), Health Promotion Research Branch.  The NCI offered me the opportunity to further explore the field of electronic health (or eHealth) on a national (U.S.) and international scale.  The term “eHealth” generally represents the use of electronic or digital information technology to assess and/or modify health behaviors, states and outcomes.

When I arrived at NCI, I was asked to bring the best and brightest behavioral researchers together to discuss how to assess health in “real-time.”  A book was published based on this meeting: “The Science of Real-Time Data Capture Self-Reports in Health Research.” Other national and international conferences followed, including the 2010 mHealth Summit, in which I was intimately involved.

How does behavioral science affect our capacity to understand the causes of cancer?

Audie Atienza: It is clear that behavioral factors contribute to cancer and many other diseases, like diabetes and heart disease.  For example, the link between smoking and cancer is well established. There is also a solid body of research that has linked obesity, physical inactivity, and poor diet to various cancers. The Centers for Disease Control (CDC) reports that 69% of U.S. adults are currently overweight or obese.[Data on adults: PDF and children: PDF]

Accurately measuring and changing these everyday health behaviors — including smoking, physical activity, what people eat — is not easy. This is where technology can be of great assistance. Through sensors, cell phones, GPS systems, social networking technology, and web-based technology, we may be able to better assess and hopefully improve these key health behaviors that contribute to cancer and other diseases.

We are, however, just at the beginning of discovering how to best develop and utilize technology to improve the health of individuals and the public.  There is much work to be done to determine what is effective and what isn’t.

How do mobile devices figure into that work?

Audie Atienza: Mobile technology is everywhere. We are seeing more integrated devices, like smartphones with cameras, accelerometers, GPS, and all types of apps.  But it isn’t about the technology — a phrase I have borrowed from Todd Park. It’s really about addressing health issues and improving the health of individuals and the public.  If technology can facilitate this, then great. But using technology may not always be the best way to improve health and well-being.  This is a critical research question.

How is mobile technology being applied to specific health issues?

Audie Atienza: Mobile technology can be (and is being) applied to address many different health and disease issues: infection disease (AIDS/HIV, tuberculosis, influenza), chronic disease (heart disease, cancer, diabetes, arthritis, asthma), mental health (depression, stress, anxiety), child and maternal health (pregnancy, infant care, childhood obesity), gerontology (healthy living in place, falls prevention, caregiving), health promotion (e.g., exercise, diet, smoking cessation, cancer screening, sun safety), and health-provider-related issues (medication adherence, patient-provider communication, point-of-care diagnostics, vital signs monitoring).

Mobile technology cuts across the disease and health spectrum with great potential to address problems that have been previously difficult to solve.  It is difficult to say which mobile health technology is most important because they are all addressing distinct and critical issues.  Heart disease and cancer are the leading causes of death in the United States. Others may argue that infectious diseases and maternal/child health are the most critical issues to address globally. Still others may argue for tobacco control and reducing obesity (increasing physical activity and improving nutrition).  The National Institutes of Health (NIH) has 27 institutes and centers (ICs), each with a particular mission.  More than 20 of the 27 ICs are currently funding mobile technology-related research.

What do we need next in mHealth?

Audie Atienza: More research. We need to better understand what works and what does not. Researchers who have systematically reviewed smartphone health apps (e.g., smoking cessation, diabetes) have found that most are not based on established public health or clinical guidelines. Very few have actually assessed whether the apps are effective in changing health outcomes. With thousands of apps, sensors, and other mobile health tools currently available, it can be difficult for the user to know what is effective, useful, and (most importantly) safe.

How close are we to a real tricorder? (There’s now an X Prize for that.)

Audie Atienza: I love science-fiction and “Star Trek”!  Certainly, mobile sensors and monitors currently exist that can accurately monitor physiological states and vital signs. And the technology is becoming increasingly integrated and more powerful.  But, to have an all-in-one mobile device that can assess and diagnose health and diseases as well as, if not better than, a clinical provider is a very tall order. If such a tool or prototype is developed, it will be science and research that will determine if the “tricorder” is effective or not.  Time will tell whether such a tool can be developed.  While I am all for reducing diagnostic errors, I personally would be hesitant to accept a diagnosis from only a mobile device without the clinical judgment of a medical or health professional.

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