Lyon, Zoe M. BA; Yang, Rachel BSE; Savoie, Marissa B. BA; Schear, Sarah MS; Dong, Jessica MD, MBA; Javaherian, Kavon MD, MBA; Hauser, Karen MD, MPH; Sarkar, Urmimala MD, MPH; Garcia-Grossman, Ilana MD Author Information

As COVID-19 spread across the globe, hospitals restricted visitors to protect patients and healthcare providers.1 The absence of in-person visitors, who play a central role in patient well-being and clinical decision making by clarifying medical histories and bridging linguistic and cultural divides, left patients vulnerable to social isolation, delirium and fragmented clinical care.2 With ongoing COVID-19 infections, health systems continue to grapple with how to support patients and loved ones during visitor restrictions.3 Many technology-driven innovations emerged during COVID-19 to conserve personal protective equipment, protect healthcare workers and prevent nosocomial transmission, but, to our knowledge, this was the first programme designed by medical trainees with the specific goal of connecting patients with their loved ones.4–8 Here, we describe the design and early impact of an inpatient video-conference telehealth initiative, and we provide a model for health systems interested in designing similar telehealth programmes to connect patients and loved ones. The objective of this initiative was to reconnect patients with their loved ones during COVID-19-related visitor restrictions across diverse hospital settings to improve patient experience and care delivery.

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Background: We conducted a randomized controlled trial of EpxDiabetes, a novel digital health intervention as an adjunct therapy to reduce HbA1c and fasting blood glucose (FBG) among patients with type 2 diabetes mellitus (T2DM). In addition, we examined the effect of social determinants of health on our system. Methods: Sixty-five (n = 65) patients were randomized at a primary care clinic. Self-reported FBG data were collected by EpxDiabetes automated phone calls or text messages. Only intervention group responses were shared with providers, facilitating follow-up and bidirectional communication. ΔHbA1c and ΔFBG were analyzed after 6 months. Results: There was an absolute HbA1c reduction of 0.69% in the intervention group (95% confidence interval [CI], -1.41 to 0.02) and an absolute reduction of 0.03% in the control group (95% CI, -0.88 to 0.82). For those with baseline HbA1c >8%, HbA1c decreased significantly by 1.17% in the intervention group (95% CI, -1.90 to -0.44), and decreased by 0.02% in the control group (95% CI, -0.99 to 0.94). FBG decreased in the intervention group by 21.6 mg/dL (95% CI, -37.56 to -5.639), and increased 13.0 mg/dL in the control group (95% CI, -47.67 to 73.69). Engagement (proportion responding to ≥25% of texts or calls over 4 weeks) was 58% for the intervention group (95% CI, 0.373-0.627) and 48% for the control group (95% CI, 0.296-0.621). Smoking, number of comorbidities, and response rate were significant predictors of ΔHbA1c. Conclusions: EpxDiabetes helps to reduce HbA1c in patients with uncontrolled T2DM and fosters patient-provider communication; it has definite merit as an adjunct therapy in diabetes management. Future work will focus on improving the acceptability of the system and implementation on a larger scale trial.

Introduction: The relationships between Alzheimer disease (AD), cognitive performance, and depression are poorly understood. It is unclear whether depressive features are a prodrome of AD. In addition, some studies of aging exclude depressed individuals, which may inappropriately limit generalizability. The aim of the present study was to determine whether depressive symptoms affect cognitive function in the context of preclinical AD. Methods: Cross-sectional multivariate analysis of participants in a longitudinal study of aging (n=356) that evaluates the influence of depressive symptoms on cognitive function in cognitively normal adults. Results: There is no relationship between the presence of depressive symptoms and cognitive function in those with either no evidence of preclinical AD or biomarker evidence of early-stage preclinical AD. However, in later stages of preclinical AD, the presence of depressive symptoms demonstrated interactive effects, including in episodic memory (0.96; 95% confidence interval, 0.31-1.62) and global cognitive function (0.46; 95% confidence interval, 0.028-0.89). Conclusions: The presence of depressive symptoms may be a late prodrome of AD. In addition, studies investigating cognitive function in older adults may not need to exclude participants with depressive symptomology, but may still consider depressive symptoms as a potential confounder in the context of more extensive neuronal injury.

Introduction: Heart failure (HF) is among the most common reasons for hospital admissions, presenting a significant cost burden to the medical system. Patients are monitored at the hospital but often go home without enough long-term management. Chronic care involving consistent symptom monitoring and patient-provider communication is essential to HF management. Though careful management can improve patient quality of life and reduce hospital readmission costs, it may be time consuming and expensive. To address this, we created a SMS text-based platform, EpxHeartFailure (EpxHF), which allows for remote patient monitoring. Our novel platform seeks to improve chronic care management by simplifying patient self-care and patient-provider communication. The goal of this low-cost intervention is to gain patient and provider acceptability and improve patient symptom stability. Methods: We conducted a retrospective review of a commercial implementation of EpxHF. Data was collected from patients over a 30-week trial period. EpxHF prompted patients to self-report body weight and symptoms of dyspnea/pedal edema (DPE), orthopnea, and edema compared to the previous day. Weight gain (>5lbs over 1 week) plus 1 other worsening symptom triggered an alert (text or call) to the patient’s provider. Providers could then contact the patient and initiate follow up care. The intervention modified message frequency to parallel each patient’s symptom stability and sent providers bimonthly triaged reports that prioritized the most unstable patients. Patients were also asked a question adapted from Kansas City Cardiomyopathy Questionnaire (KCCQ) to assess quality of life and how often a patient’s symptoms interfere with daily functioning (0 - never, 5- all the time). Results: One-hundred seventy patients in St. Louis were enrolled onto EpxHF at hospitals using care managers within risk sharing and capacitated value models. A total of 3244 texts were sent, 87 alerts were generated, and 99 communications between providers and patients were documented following alerts. The average patient engagement rate was 81%, indicating acceptability. Normalized data for DPE, orthopnea, and excessive weight gain on a scale of -1 to +1 (+1 representing symptom improvement, 0 no change, -1 worsening symptoms) indicated a clear trend of improvement on a weekly basis (avg for all patients: 0.24 DPE, 0.21 orthopnea, 0.07 excessive weight gain). At week 30, the average KCCQ score decreased by 1.38 from baseline (95% CI: 1.299-1.467), which indicates an increase in perceived quality of life. Discussion: The results demonstrate the ability of the system to engage patients, track their symptomatology and improve quality of life. EpxHF is a cost-effective tool that uses basic texting technology to help providers monitor HF patient’s fluctuating symptoms, with the goal of enabling medical intervention before a HF exacerbation occurs.

Objective: We undertook the design and implementation of a proactive telecommunication tool, EpxEpilepsy, to more accurately and frequently track seizures, thereby improving the care of epilepsy patients. Additionally, we present a cost-benefit analysis that demonstrates its capability to enable new revenue generation for providers under recent fee-for-service codes. Background: To fill in the gaps between often long periods between clinic visits, epilepsy management revolves around self-recorded seizure diaries, which can be inaccurate and incomplete. Tracking seizures with high temporal resolution is critical for medication titration, which is key to reducing the time to seizure freedom. Design/Methods: EpxEpilepsy is an automated service that uses text messages and phone communications to ask patients about seizure events. Responses are tracked and summarized for the provider both in text and graphical formats with alerts notifying the provider of high-risk individuals. 9 patients from the Washington University Epilepsy Center with a diagnosis of epilepsy were enrolled. Patients received one text message every week for 12 weeks. After the initial 4 weeks, patients were interviewed to understand their experience using EpxEpilepsy. The goal of the pilot study was to track response rates, message fatigue, the percentage of patients who reported seizure activity, and the number of seizures that could be detected by the system. Results: We achieved a 74.1% response rate (95% confidence interval ±8.38%) and detected 180 seizures, with a third of our patients at a 100% response rate. Conclusions: While the study suffers from a small sample size and a nonrandomized uncontrolled design, our data suggests that EpxEpilepsy provides a promising platform for proactive seizure tracking in epilepsy patients. As such, a randomized control trial is ongoing with a larger sample size examining EpxEpilepsy’s effect on time to seizure freedom. Disclosure: Dr. Zhang has nothing to disclose. Dr. Chen has nothing to disclose. Dr. Javaherian has nothing to disclose. Dr. Groenendyk has nothing to disclose. Dr. Pan has nothing to disclose. Dr. Maccotta has nothing to disclose.

Background Telemedicine has emerged as an innovative platform to diagnose and treat psychiatric disorders in a cost-effective fashion. Previous studies have laid the functional framework for monitoring and treating child psychiatric disorders electronically using videoconferencing, mobile phones (smartphones), and Web-based apps. However, phone call and text message (short message service, SMS) interventions in adolescent psychiatry are less studied than other electronic platforms. Further investigations on the development of these interventions are needed. Objective The aim of this paper was to explore the utility of text message interventions in adolescent psychiatry and describe a user feedback-driven iterative design process for text message systems. Methods We developed automated text message interventions using a platform for both depression (EpxDepression) and autism spectrum disorder (ASD; EpxAutism) and conducted 2 pilot studies for each intervention (N=3 and N=6, respectively). The interventions were prescribed by and accessible to the patients’ healthcare providers. EpxDepression and EpxAutism utilized an automated system to triage patients into 1 of 3 risk categories based on their text responses and alerted providers directly via phone and an online interface when patients met provider-specified risk criteria. Rapid text-based feedback from participants and interviews with providers allowed for quick iterative cycles to improve interventions. Results Patients using EpxDepression had high weekly response rates (100% over 2 to 4 months), but exhibited message fatigue with daily prompts with mean (SD) overall response rates of 66.3% (21.6%) and 64.7% (8.2%) for mood and sleep questionnaires, respectively. In contrast, parents using EpxAutism displayed both high weekly and overall response rates (100% and 85%, respectively, over 1 to 4 months) that did not decay significantly with time. Monthly participant feedback surveys for EpxDepression (7 surveys) and EpxAutism (18 surveys) preliminarily indicated that for both interventions, daily messages constituted the “perfect amount” of contact and that EpxAutism, but not EpxDepression, improved patient communication with providers. Notably, EpxDepression detected thoughts of self-harm in patients before their case managers or caregivers were aware of such ideation. Conclusions Text-message interventions in adolescent psychiatry can provide a cost-effective and engaging method to track symptoms, behavior, and ideation over time. Following the collection of pilot data and feedback from providers and patients, larger studies are already underway to validate the clinical utility of EpxDepression and EpxAutism. Trial Registration Clinicaltrials.gov NCT03002311; https://clinicaltrials.gov/ct2/show/NCT03002311 (Archived by WebCite at http://www.webcitation.org/6qQtlCIS0)

BACKGROUND:Although hypertension (HTN) is a major modifiable risk factor for arterial damage, blood pressure (BP) remains poorly controlled in the hypertensive population. Telemedicine is a promising adjunct intervention that may complement traditional therapies and improve adherence rates; however, current approaches have multiple barriers to entry, including the use of relatively expensive Bluetooth devices or the dependence on smart phone utilization, which tend to exclude low-income and more elderly populations.OBJECTIVE:The aim of this study was to design and implement a new phone call- and short message service text messaging-based intervention, Epharmix's EpxHypertension, in a quality improvement project that demonstrates the feasibility of this system for BP control in a family medicine setting.METHODS:We recruited 174 patients from a community clinic in St Louis from a database of patients diagnosed with HTN. An automated call or text messaging system was used to monitor patient-reported BPs. If determined to be elevated, physicians were notified by an email, text, or electronic medical record alert. Mean systolic BPs (SBPs) and diastolic BPs (DBPs) were compared at the beginning and end of 12 weeks.RESULTS:After 12 weeks on the system, patients with a baseline SBP of 140 mm Hg or higher reduced SBP by 10.8 mm Hg (95% CI -14.5 to -7.2, P<.001) and DBP by 6.6 mm Hg (95% CI -9.9 to -3.4, P=.002), but no significant changes were observed in overall BPs and BPs in the group with baseline SBP less than 140 mm Hg.CONCLUSIONS:EpxHypertension provides a viable means to control HTN in patients with high baseline BPs despite previous therapy. This community implementation study demonstrates the feasibility of implementing EpxHypertension across a primary care setting without the need for smartphones or Bluetooth-linked BP cuffs. Future studies should evaluate its effectiveness in a randomized control trial compared with standard of care.

BACKGROUND:Type II diabetes mellitus (T2DM) presents a major disease burden in the United States. Outpatient glycemic control among patients with T2DM remains difficult. Telemedicine shows great potential as an adjunct therapy to aid in glycemic control in real-world settings.OBJECTIVE:We aimed to explore the effectiveness of EpxDiabetes, a novel digital health intervention, in improving hemoglobin A1c (HbA1c) and fasting blood glucose (FBG) among patients with uncontrolled diabetes.METHODS:We recruited 396 patients from a community clinic in St. Louis, Missouri, from a database of patients diagnosed with T2DM and with a most recent HbA1c >7% as part of a quality improvement project. An automated call or text-messaging system was used to monitor patient-reported FBG. If determined to be elevated, care managers were notified by email, text, or electronic medical record alert. Participants self-reported their FBG data by replying to EpxDiabetes automated phone calls or text messages. Data were subsequently analyzed, triaged, and shared with providers to enable appropriate follow-up and care plan adjustments. Absolute HbA1c reduction, patient engagement, and absolute patient-reported FBG reduction were examined at approximately 6 months post implementation.RESULTS:EpxDiabetes had an average 95.6% patient response rate to messages at least once per month and an average 71.1% response rate to messages at least once per week. Subsequent HbA1c drop with EpxDiabetes use over 4 months was -1.15% (95% CI -1.58 to -0.71) for patients with HbA1c >8% at baseline compared to the change in HbA1c over 4 months prior to the implementation of EpxDiabetes of only -0.005 points (95% CI -0.28 to 0.27), P=.0018.CONCLUSIONS:EpxDiabetes may help reduce HbA1c in patients with high HbA1c baselines (>8%). The intervention demonstrates high patient engagement sustainable for at least 6 months.

BACKGROUND:Patient noncompliance with therapy, treatments, and appointments represents a significant barrier to improving health care delivery and reducing the cost of care. One method to improve therapeutic adherence is to improve feedback loops in getting clinically acute events and issues to the relevant clinical providers as necessary (ranging from detecting hypoglycemic events for patients with diabetes to notifying the provider when patients are out of medications). Patients often don't know which information should prompt a call to their physician and proactive checks by the clinics themselves can be very resource intensive. We hypothesized that a two-way SMS system combined with a platform web service for providers would enable both high patient engagement but also the ability to detect relevant clinical alerts.OBJECTIVE:The objectives of this study are to develop a feasible two-way automated SMS/phone call + web service platform for patient-provider communication, and then study the feasibility and acceptability of the Epharmix platform. First, we report utilization rates over the course of the first 18 months of operation including total identified clinically significant events, and second, review results of patient user-satisfaction surveys for interventions for patients with diabetes, COPD, congestive heart failure, hypertension, surgical site infections, and breastfeeding difficulties.METHODS:To test this question, we developed a web service + SMS/phone infrastructure ("Epharmix"). Utilization results were measured based on the total number of text messages or calls sent and received, with percentage engagement defined as a patient responding to a text message at least once in a given week, including the number of clinically significant alerts generated. User satisfaction surveys were sent once per month over the 18 months to measure satisfaction with the system, frequency and degree of communication. Descriptive statistics were used to describe the above information.RESULTS:In total, 28,386 text messages and 24,017 calls were sent to 929 patients over 9 months. Patients responded to 80% to 90% of messages allowing the system to detect 1164 clinically significant events. Patients reported increased satisfaction and communication with their provider. Epharmix increased the number of patient-provider interactions to over 10 on average in any given month for patients with diabetes, COPD, congestive heart failure, hypertension, surgical site infections, and breastfeeding difficulties.CONCLUSIONS:Engaging high-risk patients remains a difficult process that may be improved through novel, digital health interventions. The Epharmix platform enables increased patient engagement with very low risk to improve clinical outcomes. We demonstrated that engagement among high-risk populations is possible when health care comes conveniently to where they are.

Objectives Effective oral therapies for hepatitis B and C have recently been developed, while there are no approved pharmacological therapies for alcoholic and non-alcoholic fatty liver diseases (ALD and NAFLD). We hypothesise that fewer advances in fatty liver diseases could be related to disparities in research attention. Methods We developed the Attention-to-Burden Index (ABI) that compares the research activities during 2010–2014, and an estimate of disease burden of these 4 major liver diseases. The resulting ratio reflects either overattention (positive value) or inadequate attention (negative value) compared with disease burden. The mean research attention and disease burden were calculated from 5 and 6 different parameters, respectively. The efficacy rate of current pharmacological therapies was assessed from published clinical trials. Findings The mean research attention for hepatitis B and C was 31% and 47%, respectively, while NAFLD and ALD received 17% and 5%. The overall burden was 5% and 28% for hepatitis B and C, and 17% and 50% for NAFLD and ALD. The calculated ABI for hepatitis B and C revealed a +6.7-fold and +1.7-fold overattention, respectively. NAFLD received an appropriate attention compared with its burden, while ALD received marked inadequate attention of −9.7-fold. The efficacy rate of current pharmacological agents was 72% for hepatitis B, 89% for hepatitis C, 25% for non-alcoholic steatohepatitis and 13% for alcoholic hepatitis. Importantly, we found a positive correlation between the mean attention and the efficacy rate of current therapies in these 4 major liver diseases. Interpretation There are important disparities between research attention and disease burden among the major liver diseases. While viral hepatitis has received considerable attention, there is a marked inadequate attention to ALD. There is a critical need to increase awareness of ALD in the liver research community.

Background: Medication adherence remains a difficult problem to both assess and improve in patients. It is a multifactorial problem that goes beyond the commonly cited reason of forgetfulness. To date, eHealth (also known as mHealth and telehealth) interventions to improve medication adherence have largely been successful in improving adherence. However, interventions to date have used time- and cost-intensive strategies or focused solely on medication reminding, leaving much room for improvement in using a modality as flexible as eHealth.Objective: Our objective was to develop and implement a fully automated short message service (SMS)-based medication adherence system, EpxMedTracking, that reminds patients to take their medications, explores reasons for missed doses, and alerts providers to help address problems of medication adherence in real time.Methods: EpxMedTracking is a fully automated bidirectional SMS-based messaging system with provider involvement that was developed and implemented through Epharmix, Inc. Researchers analyzed 11 weeks of de-identified data from patients cared for by multiple provider groups in routine community practice for feasibility and functionality. Patients included were those in the care of a provider purchasing the EpxMedTracking tool from Epharmix and were enrolled from a clinic by their providers. The primary outcomes assessed were the rate of engagement with the system, reasons for missing doses, and self-reported medication adherence.Results: Of the 25 patients studied over the 11 weeks, 3 never responded and subsequently opted out or were deleted by their provider. No other patients opted out or were deleted during the study period. Across the 11 weeks of the study period, the overall weekly engagement rate was 85.9%. There were 109 total reported missed doses including "I forgot" at 33 events (30.3%), "I felt better" at 29 events (26.6%), "out of meds" at 20 events (18.4%), "I felt sick" at 19 events (17.4%), and "other" at 3 events (2.8%). We also noted an increase in self-reported medication adherence in patients using the EpxMedTracking system.Conclusions: EpxMedTracking is an effective tool for tracking self-reported medication adherence over time. It uniquely identifies actionable reasons for missing doses for subsequent provider intervention in real time based on patient feedback. Patients enrolled on EpxMedTracking also self-report higher rates of medication adherence over time while on the system.