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A Call for Mobile Chronic Disease Management
By Anand K. Iyer and Mark Cramer

While private, public, and academic “pockets” have made advances in chronic disease management, there is a largely untapped, nontraditional, and innovative method that may effectively help better treat these conditions. By integrating clinical, behavioral, and motivational applications with everyday technologies such as cell phones and the Internet, mobile chronic disease management (mCDM) can engage patients and healthcare providers in ways that improve outcomes and reduce healthcare costs.

mCDM can be best defined as a solution platform born from the convergence of clinical, evidence-based medicine; wireless device and services innovation; medical device innovation; behavioral science; social networking; HIT infrastructure; and family and peer support programs. And while mobile technologies such as sensors, services, infrastructure, and even economic models are core to the success of mCDM, its ultimate success will be driven by other factors.   

In 2009, the cost of chronic diseases in the United States neared $2 trillion and represented nearly 80% of healthcare expenses.  Nearly 86 million Americans have not had any healthcare insurance coverage in the last two years, and less than one half have full healthcare coverage.  The pharmaceutical industry notes the current state of medication adherence, which for many drug classes quickly drops to below 30% in a matter of two to three refill periods for a given drug and disease.  And disease management, the “high-attention” call-center-based services, are tapping into every avenue to determine how to raise engagement rates from levels that many in the disease management sector report below 5%. 

There are real barriers to chronic disease management that must be taken into consideration, such as the following:

• CDM is burdensome for patients. Patients must log significant amounts of various data (eg, medication use, physical and psychological symptoms, episodic testing, activity, nutrition) throughout any given day. 

• Patients have limited support outside the clinical setting. The U.S. healthcare system was designed to support acute care rather than CDM. This is particularly true when considering the increasing rate of chronic disease in this country and worldwide.  Studies have shown that patients forget 80% of their physicians’ instructions within three months; patients need access to relevant and timely education outside of their healthcare provider's office. 

•Healthcare providers don’t get the data they need. Healthcare providers often have limited, incomplete, and/or inaccurate information to use as a basis for treatment or to make medication modifications.

• Office visits are generally too short and too infrequent. Typically, physicians have 15 minutes or less during a patient office visit to review charts, examine patients, analyze data, and develop a report.  A typical patient may only see his or her physician two or three times per year; thus, patients do not receive the levels of support and feedback that are essential for them to effectively sustain their CDM efforts. 

• Primary care physicians aren’t always aware of the latest evidence-based guidelines. As the gatekeepers to our healthcare system, primary care doctors see and treat the majority of patients in the United States.  In the current clinical paradigm, it is unrealistic to expect primary care physicians to know and treat according to the latest evidence-based guidelines for all chronic diseases.  To do so, they need technological support that fits within their practices and workflow.

These barriers can likely be broken down by access to real-time information. Wireless communications provide us with the opportunity to do just that.

In 2009, cellular penetration in the United States reached 90% of the population, topping 285 million subscribers, according to CTIA-The Wireless Association, which also reports that  monthly text messaging volume has grown from 5.8 billion messages in 2005 to more than 1 trillion in 2009. 

Combining these indicates there is an opportunity to leverage the cellular platform as a means of providing actionable healthcare information access to those who do not have access to traditional care means.  Also, the United States has an opportunity to leverage a lower-cost platform to connect patients and providers and offer actionable care at the point of care at the right time and in a manner that fits into the day-to-day lives of patients and the clinical workflow of providers. 

So what will it take to bring this opportunity to fruition?  The answer may lie in public-private partnerships and clearly defined roles for industry stakeholders, public stakeholders, and the academic community. 

The following are the top recommendations that could make mCDM a focal point of our healthcare system:

• mCDM must be addressed as a macroeconomic problem, not just as a health problem.

• Effective mCDM requires fundamental paradigm shifts in strategy and healthcare delivery.

• mCDM must harness the power of both standard mobile and device-to-device communications.

• mCDM must integrate real-time data to focus on prevention, maintenance, and population health management.

• mCDM must coexist with EMRs to integrate real-time patient information to improve clinical workflow.

• mCDM must drive engagement by providing data to create awareness and enable social connections.

• mCDM must integrate caregiver support tools to manage a diverse set of interactions.

• To sustain ongoing outcomes, mCDM must provide stimuli that guide behavior and consequences that reinforce behavior.

• mCDM must incorporate alternative incentives to break down barriers to patient self-management.

These recommendations should be integrated into an mCDM reference architecture.

The end goal of mCDM is simple: to improve the lives of people with chronic diseases with better health outcomes and lower costs.

— Anand K. Iyer is president and chief operating officer of WellDoc, Inc, a healthcare company that uses technology to improve disease management outcomes and reduce healthcare costs.                                      

— Mark Cramer is CEO of The Institute for Defense & Business, a nonprofit research and education institute formed in 1997 by the University of North Carolina-Chapel Hill and the state of North Carolina. The institute offers a series of education programs for the military, government, nongovernmental agencies, and private industry in the areas of logistics, operations, life cycle management, organizational change, and economic stabilization.