application of behavioral health technology tools in the clinical care of mild traumatic brain...
TRANSCRIPT
Application of Behavioral Health Technology Tools
in the Clinical Care of mTBIJanuary 15, 2015, 1-2:30pm (EST)
Maj. Pamela DiPatrizio, AN, MSN, CEN, CPEN
Chief, Office of Education Outreach
Defense and Veterans Brain Injury Center (DVBIC)
Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury (DCoE)
Silver Spring, Md.
David C. Cooper, Psy.D.
Clinical Psychologist, Mobile Applications Lead
National Center for Telehealth & Technology (T2)
Defense Centers of Excellence for Psychological
Health and Traumatic Brain Injury (DCoE)
Joint Base Lewis-McChord, Wash.
Presenters:
Moderator:
Webinar Overview
The Clinical Practice Guidelines produced by the departments of Defense and
Veterans Affairs provide a framework for ensuring evidence-based care for
patients with mTBI. This webinar will demonstrate two mobile applications
produced by the National Center for Telehealth & Technology that offer providers
evidence-informed tools for the treatment and engagement in clinical care of
patients with mTBI. The presenter will review some of the empirical findings that
support the use of these apps, and will demonstrate how to incorporate these
tools into current clinical practice. In addition, he will highlight several emerging
tools that may have some promise for future use with this population.
During this webinar, participants will learn to:
Compare innovative, behavioral-health technology tools and describe some of
the empirical evidence for their integration in clinical care with mTBI patients.
Discuss the use of behavioral-health technology tools as assistive devices in
mTBI rehabilitation to facilitate recovery from the adverse effects of mTBI and
increase engagement in care.
Distinguish between evidence-based standard of care, as described in the
Clinical Practice Guidelines and the acceptable use of evidence-informed
technology tools to supplement clinical care.
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David Cooper, Psy.D.
3
Dr. David Cooper is a Clinical Psychologist and
the Mobile Health Program Lead at the National
Center for Telehealth & Technology (T2).
He earned his Psy.D. and M.A. in Clinical
Psychology from the American School of
Professional Psychology at Argosy University in
Washington, DC.
Dr. Cooper has been involved in a number of
development projects at T2, including an
application that was selected by the Senior
Military Medical Advisory Committee to be part of
a national pilot study looking at innovative ways
to reduce obesity.
Photo courtesy of: David C. Cooper, PsyD
Disclosures
The views expressed in this presentation are those of the
presenter and do not reflect the official policy of the
Department of Defense or the U.S. Government.
Dr. Cooper has no relevant financial relationships to disclose.
Dr. Cooper will be discussing web and mobile applications
that have been developed by the Defense Department,
including those developed by the National Center for
Telehealth & Technology (T2). Some of these applications
may fall under FDA device regulations, and in those cases we
will consult with the USAMRMC Division of Regulated
Activities and Compliance for guidance.
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T2 is…
The National Center for Telehealth & Technology
A DoD source for:
Telehealth policy
Research on suicide prevention, TBI, and psychological health
Mobile applications
Websites
Innovation
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Polling Question #1
How do you think technology could help
you improve what you’re already doing?
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Framework for mTBI care in VA/DoD
VA/DoD Clinical Practice Guidelines
Promotes evidence-based assessment,
diagnosis, treatment and management of patients
diagnosed with mTBI
Provides guidelines and recommendations
regarding:
Return to Work/Duty Activity
Early Intervention
Symptom Management
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(Department of Veterans Affairs/Department of Defense, 2009)
Times are a’ changing
For 50 years little changed in mTBI
assessment and treatment
LOTS of paper
Same tools
But in the last 5 – 10 years, we have seen
an explosion of new possibilities, including
renewed efforts to identify optimal methods
of TBI rehab(Cifu et al., 2010)
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mTBI Rehabilitation
Substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychological rehabilitation after TBI (Cicerone et al., 2011)
Lots of challenges
Symptom Management
Compliance
Return to Duty
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mTBI Symptom Management
Common symptoms post-injury
Headaches
Sleep disturbances
Mood changes
Decreased coordination or balance
Fatigue
Nausea (Hoge, McGurk, Thomas, Cox, Engel & Castro, 2008; Kashluba, Paniak & Casey, 2008)
All are challenging enough for us, much less
someone with mTBI
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Return to Duty
On-the-job training
Activities of daily living (ADLs)
Research is unclear on why some patients
slow to return (Wäljas et al., 2014)
Technology offers some possible solutions
to help
Need to separate the good from the bad
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Clinical Reasoning w/ Technology
Yamkovenko (2014) conducted an interview with occupational therapists, Rob Ferguson, MHS, OTRL and Doug Rakoski, OTD, OTR/L, ATPfrom the University of Michigan, and discussed how their use of technology in the clinical care of stroke patients has: Expanded evidence-based practice with everyday
tools
Allowed technology to facilitate motor, cognitive, and perceptual abilities
Encouraged high repetitions of activity in engaging technologies, such as video games
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Phone as Assistive Device
Assistive technology for cognition (ATC)
Cost-effective
Early intervention
Emotionally supportive
Adaptable, ubiquitous workflow
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Phone as Assistive Device
Cost-effective
Particularly when compared to time in the clinic(Luxton, Hansen & Stanfill, 2014)
Early intervention
Allows for evidence-based practice to
begin even before intake
Takes into account current challenges(Hyatt, Davis, & Barroso, 2014)
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Phone as Assistive Device
Emotionally supportive
Working with what the patient wants, rather
than forcing what we want
Adaptable, ubiquitous workflow
Works in home, office, clinic, etc.
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But what about…?
Are they available to those with low income?
Do they work the same?
Is there an evidence base?
Do patients like it?
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Available to low income?
Of adults making less than $30K…
77% 18-29 own a smartphone
47% 30-49 own a smartphone
45% go online mostly with their smartphone
Rates rising ~15-20% over the past few years
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(Smith, 2013)
Do they work the same?
Assessments
Psychometrically equivalent
Treatments
Research showing good effect sizes
Web: high effects, around .5 or greater (Richards & Richardson, 2012)
Apps: moderate to high effects, around .3 to .5(Donker et al., 2013)
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Is there an evidence base?
Effective tool for symptom management and symptom assessments are psychometrically valid(Bush, Skopp, Smolenski, Crumpton, & Fairall, 2013; Donker, Petrie, Proudfoot, Clarke, Birch, & Christensen, 2013; Gaggioli, & Riva, 2013)
Again, similar effect sizes(Richards & Richardson, 2012; Donker et al., 2013)
Translational research Challenging to be on the forefront
Evidence-informed practice Evidence-based
Requires knowledge of both
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Do patients like it?
Age dependent but…
70% would like to download an app to
their phone in order to track their condition
on a daily basis (Torous et al., 2014)
Similar for veterans (Erbes et al., 2014)
Tech is one way, shouldn’t be the only way
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Specific Apps and
Specific Problems
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T2 Mood Tracker
Monitor and track emotional
experiences over a period of days,
weeks and months.
Features
Self-rating on pre-populated categories
Full note adding
Graphed results
Fully customizable categories
User-set reminders for self-rating
Send results to providers
Photo by: National Center for Telehealth & Technology22
T2 Mood Tracker
Track a variety of factors
Emotional health
Pain
Sharp vs. dull
Intense vs. slight
Constant vs. brief
Research support (Bush et al., 2013; Bush, Ouelette & Kinn, 2014)
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Adding / modifying scales
Photo by: National Center for Telehealth & Technology
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T2 Mood Tracker
Photo by: National Center for Telehealth & Technology
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Concussion Coach
Concussion Coach was designed for veterans,
service members, and others who have
symptoms that may be related to concussion,
or mild-to-moderate traumatic brain injury. This
app can be used by itself, but it may be more
helpful when used along with treatment from a
health provider.
Features include:
Education on symptoms and treatment.
Tools for screening / tracking symptoms.
Relaxation exercises and tools for
managing problems related to concussion.
Direct links for community-based resources
and support.
26 Photo by: National Center for Telehealth & Technology
Concussion Coach
All-in-one tool
Sections
Learn
Self-assessment Subjective Units of Distress Scale (SUDS)
Neurobehavioral Symptom Inventory (NSI)
Manage this moment
Build resilience
Resources and support
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Learning and Assessment
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Photo by: National Center for Telehealth & Technology
Tools
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Photo by: National Center for Telehealth & Technology
Resources
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Photo by: National Center for Telehealth & Technology
CBTi (Insomnia) Coach
T2 collaborated with the VA's National
Center for PTSD to develop this app to
assist veterans and active duty personnel
(and civilians) who are experiencing
symptoms of insomnia. It is intended to be
used as an adjunct to psychological
treatment but can also serve as a stand-
alone education tool.
Features:
Self-assessment of insomnia symptoms
Sleep diary to track sleep habits
Sleep “prescription” to regulate wake and
bed times
Assistance in finding immediate support
Customized support information
31 Photo by: National Center for Telehealth & Technology
CBTi Coach
Sections
Sleep Diary
Tools
Progressive relaxation, cognitive exercises
Assessment
Insomnia Severity Index (ISI)
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Diary & Assessment
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Photo by: National Center for Telehealth & Technology
Tools & Information
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Photo by: National Center for Telehealth & Technology
Tools & Information
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Photo by: National Center for Telehealth & Technology
mTBI Pocket Guide
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Clinical Practice Guidelines for
treatment of mild Traumatic Brain
Injury
Features:
Quick results with coding guidance
Symptom management lists
Summary of clinical
recommendations
Patient education resources
Clinical tools and resources
Photo by: National Center for Telehealth & Technology
Polling Question #2
Now that you’ve heard more, how likely
are you to use some of these mobile apps
with your patients?
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Polling Question #3
• What would make you more likely to use
these and other apps with patients?
38
Reading
RSVP (Rapid Serial Visual Presentation)
Spritz / Squirt
(Squirt.io)
Potential to help with saccadic provoked
symptoms post-injury.
39
Photo by: http://www.spritzinc.com/test
Looking ahead
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Time Management
Pomodoro
http://www.brainlinemilitary.org/content/multime
dia.php?id=7779
Many apps to help / augment time
management
More incorporating automatic / natural
language entry.
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Mobile games for
Occupational Therapy
Emerging movements for fine motor
recovery
Start on an iPad and work down.
Incorporate accessories that can reinforce
skills
Bluetooth buttons, stylus
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Next Steps
Download apps for yourself
Staying up-to-date
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Next Steps
Challenges Integrating this into your workflow
Nothing works with the EHR…yet
Can’t send data in a HIPAA-compliant way
Finding quality tools No central source
Boudreaux et al. (2014) summarizes seven strategies for evaluating and selecting health-related apps:
1. Review scientific literature
2. Search app clearinghouse websites
3. Search app stores
4. Review app descriptions, user ratings, and reviews
5. Conduct a social media query
6. Pilot the apps
7. Elicit feedback from patients
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Summary
During this webinar, participants will learn to:
Compare innovative, behavioral-health technology tools and
describe some of the empirical evidence for their integration
in clinical care with mTBI patients.
Discuss the use of behavioral-health technology tools as
assistive devices in mTBI rehabilitation to facilitate recovery
from the adverse effects of mTBI and increase engagement
in care.
Distinguish between evidence-based standard of care, as
described in the Clinical Practice Guidelines and the
acceptable use of evidence-informed technology tools to
supplement clinical care.
45
Additional mTBI Resources
Defense Centers of Excellence for Psychological Health and Traumatic Brain Injury (DCoE)
http://www.dcoe.mil/TraumaticBrainInjury/Tips_for_Treating_mTBI/TBI_Information.aspx
Defense and Veterans Brain Injury Center (DVBIC)
http://www.dvbic.org
Deployment Health Clinical Center (DHCC)
http://www.pdhealth.mil/TBI.asp
The Center of Excellence for Medical Multimedia
http://www.traumaticbraininjuryatoz.org
Brain Injury Association of America
http://www.biausa.org
Brainline (WETA)
http://www.brainline.org
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References
Boudreaux, E. D., Waring, M. E., Hayes, R. B., Sadasivam, R. S., Mullen, S., & Pagoto, S. (2014). Evaluating
and selecting mobile health apps: Strategies for healthcare providers and healthcare organizations.
Translational Behavioral Medicine, Advanced online publication
Bush, N. E., Ouelette, G., & Kinn, J. (2014b). Utility of the T2 Mood Tracker mobile application among Army
Warrior Transition Unit service members. Military Medicine, In press.
Bush, N. E., Skopp, N. A., Smolenski, D., Crumpton, R., & Fairall, J. (2013b). Behavioral screening measures
delivered with a smartphone ‘app’: Psychometric properties and user preference. Journal of Nervous and
Mental Disease, 201(11), 991-995.
Cicerone, K. D., Langenbahn , D. M., Braden, C., Malec, J. F., Kalmar, K., Fraas, M., Felicetti, T., Laatsch, L.,
Harley, J. P., Bergquist , T., Azulay, J., Cantor, J., Ashman , T. (2011). Archives of Physical Medicine and
Rehabilitation, 92 (4), 519-530.
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References
Cifu, D. X., Cohen, S. I., Lew, H. L., Jaffee, M., & Sigford, B. (2010). The history and evolution of traumatic
brain injury rehabilitation in military service members and veterans. American Journal of Physical
Medicine & Rehabilitation / Association of Academic Physiatrists, 89(8), 688–694.
doi:10.1097/PHM.0b013e3181e722ad
Department of Veterans Affairs/Department of Defense (2009). VA/DoD Clinical practice guideline for the
management of concussion and mild traumatic brain injury, version 1.0. Washington, DC: Veterans
Health Administration, Department of Defense.
Department of Defense, Defense Centers of Excellence for Psychological Health & Traumatic Brain Injury,
Portable Field-Based Devices for the Early Diagnosis of Mild Traumatic Brain Injury, September 20,
2010.
Donker, T., Petrie, K., Proudfoot, J., Clarke, J., Birch, M. R., & Christensen, H. (2013). Smartphones for
smarter delivery of mental health programs: A systematic review. Journal of Medical Internet Research,
15(11), e247.48
References
Erbes, C. R., Stinson, R., Kuhn, E., Polusny, M., Urban, J., Hoffman, J., … Thorp, S. R. (2014). Access,
Utilization, and Interest in mHealth Applications Among Veterans Receiving Outpatient Care for PTSD.
Military Medicine, 179(11), 1218–1222. doi:10.7205/MILMED-D-14-00014
Gaggioli, A., & Riva, G. (2013). From mobile mental health to mobile wellbeing: Opportunities and challenges.
Studies in Health Technology and Informatics, 184, 141-147.
Hoge, C.W ., McGurk, D., Thomas, J., Cox ,A., Engel, C., & Castro, C. A. (2008). Mild traumatic brain injury
in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358 (5), 455-63.
Hyatt, K., Davis, L. L., & Barroso, J. (2014). Chasing the care: soldiers experience following combat-related
mild traumatic brain injury. Military Medicine, 179(8), 849–855. doi:10.7205/MILMED-D-13-00526
Kashluba, S., Paniak, C., & Casey, J. E. (2008). Persistent symptoms associated with factors identified by the
WHO Task Force on Mild Traumatic Brain Injury. Clinical Neuropsychology, 22, 195-208.
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Luxton, D. D., Hansen, R. N., & Stanfill, K. (2014). Mobile app self-care versus in-office care for stress
reduction: A cost-minimization analysis. Journal of Telemedicine and Telecare, Advanced online
publication.
Richards, D., & Richardson, T. (2012). Computer-based psychological treatments for depression: A
systematic review and meta-analysis. Clinical Psychology Review, 32(4), 329-342.
Smith, A. (2013, October 8). Technology Adoption by Lower Income Populations | Pew Research Center’s
Internet & American Life Project. Retrieved from http://www.pewinternet.org/2013/10/08/technology-
adoption-by-lower-income-populations/
Torous, J., Friedman, R., & Keshvan, M. (2014). Smartphone ownership and interest in mobile applications
to monitor symptoms of mental health conditions. JMIR mhealth and uHealth, 2(1), e2. DOI:
10.2196/mhealth.2994
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References
Wäljas, M., Iverson, G. L., Lange, R. T., Liimatainen, S., Hartikainen, K. M., Dastidar, P., … Öhman, J.
(2014). Return to Work Following Mild Traumatic Brain Injury: Journal of Head Trauma
Rehabilitation, 29(5), 443–450. doi:10.1097/HTR.0000000000000002
Yamkovenko, S. (2014, December 1). Clinical Reasoning with Everyday Technology - AOTA. Retrieved
December 17, 2014, from http://www.aota.org/Publications-News/AOTANews/2014/QA-Stroke-
rehab-technology.aspx?utm_source=AOTA&utm_medium=front-page&utm_campaign=stroke-tech
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References
Save the Date
Next DCoE Telehealth & Technology Webinar:
Date/Time: Thursday February 19, 2015, 1-2:30pm EST
Title: Clinical Benefits of Technology in Behavioral Health Care
Next DCoE Psychological Health Webinar:
Date/Time: Thursday February 26, 2015, 1-2:30pm EST
Title: Physical Symptoms and Mental Health
Next DCoE TBI Webinar:
Date/Time: Thursday February 12, 2015, 1-2:30pm EST
Title: Progressive Return to Activity Following Mild TBI: A Refresh
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DCoE Contact Info
DCoE Outreach Center
1-866-966-1020 (toll-free)
http://www.dcoe.mil/
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