Enhancing Patient Activation and Self-Management Activities in Patients With Type 2 Diabetes Using the US Department of Defense Mobile Health Care Environment: Feasibility Study.

BACKGROUND: Past mobile health (mHealth) efforts to empower type 2 diabetes (T2D) self-management include portals, text messaging, collection of biometric data, electronic coaching, email, and collection of lifestyle information. OBJECTIVE: The primary objective was to enhance patient activation and self-management of T2D using the US Department of Defense's Mobile Health Care Environment (MHCE) in a patient-centered medical home setting. METHODS: A multisite study, including a user-centered design and a controlled trial, was conducted within the US Military Health System. Phase I assessed preferences regarding the enhancement of the enabling technology. Phase II was a single-blinded 12-month feasibility study that randomly assigned 240 patients to either the intervention (n=123, received mHealth technology and behavioral messages tailored to Patient Activation Measure [PAM] level at baseline) or the control group (n=117, received equipment but not messaging. The primary outcome measure was PAM scores. Secondary outcome measures included Summary of Diabetes Self-Care Activities (SDSCA) scores and cardiometabolic outcomes. We used generalized estimating equations to estimate changes in outcomes. RESULTS: The final sample consisted of 229 patients. Participants were 61.6% (141/229) male, had a mean age of 62.9 years, mean glycated hemoglobin (HbA1c) of 7.5%, mean BMI of 32.7, and a mean duration of T2D diagnosis of 9.8 years. At month 12, the control group showed significantly greater improvements compared with the intervention group in PAM scores (control mean 7.49, intervention mean 1.77; P=.007), HbA1c (control mean -0.53, intervention mean -0.11; P=.006), and low-density lipoprotein cholesterol (control mean -7.14, intervention mean 4.38; P=.01). Both groups showed significant improvement in SDSCA, BMI, waist size, and diastolic blood pressure; between-group differences were not statistically significant. Except for patients with the highest level of activation (PAM level 4), intervention group patients exhibited significant improvements in PAM scores. For patients with the lowest level of activation (PAM level 1), the intervention group showed significantly greater improvement compared with the control group in HbA1c (control mean -0.09, intervention mean -0.52; P=.04), BMI (control mean 0.58, intervention mean -1.22; P=.01), and high-density lipoprotein cholesterol levels (control mean -4.86, intervention mean 3.56; P<.001). Significant improvements were seen in AM scores, SDSCA, and waist size for both groups and in diastolic and systolic blood pressure for the control group; the between-group differences were not statistically significant. The percentage of participants who were engaged with MHCE for ≥50% of days period was 60.7% (68/112; months 0-3), 57.4% (62/108; months 3-6), 49.5% (51/103; months 6-9), and 43% (42/98; months 9-12). CONCLUSIONS: Our study produced mixed results with improvement in PAM scores and outcomes in both the intervention and control groups. Structural design issues may have hampered the influence of tailored behavioral messaging within the intervention group. TRIAL REGISTRATION: ClinicalTrials.gov NCT02949037; https://clinicaltrials.gov/ct2/show/NCT02949037. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.6993.

mCare: using secure mobile technology to support soldier reintegration and rehabilitation.

BACKGROUND: The U.S. Army Medical Department conducted a pilot mobile health project to determine the requirements for coordination of care for "Wounded Warriors" using mobile messaging. The primary objective was to determine if a secure mobile health (mhealth) intervention provided to geographically dispersed patients would improve contact rates and positively impact the military healthcare system. METHODS AND MATERIALS: Over 21 months, volunteers enrolled in a Health Insurance Portability and Accountability Act-compliant, secure mobile messaging initiative called mCare. The study included males and females, 18-61 years old, with a minimum of 60 days of outpatient recovery. Volunteers were required to have a compatible phone. The mhealth intervention included appointment reminders, health and wellness tips, announcements, and other relevant information to this population exchanged between care teams and patients. RESULTS: Provider respondents reported that 85% would refer patients to mCare, and 56% noted improvement in appointment attendance (n=90). Patient responses also revealed high acceptability of mCare and refined the frequency and delivery times (n=114). The pilot project resulted in over 84,000 outbound messages and improved contact rates by 176%. CONCLUSIONS: The mCare pilot project demonstrated the feasibility and administrative effectiveness of a scalable mhealth application using secure mobile messaging and information exchanges, including personalized patient education.

National Emergency Tele-Critical Care in a Pandemic: Barriers and Solutions.

The COVID-19 pandemic caused tremendous disruption to the U.S. healthcare system and nearly crippled some hospitals during large patient surges. Limited ICU beds across the country further exacerbated these challenges. Telemedicine, specifically tele-critical care (TCC), can expand a hospital's clinical capabilities through remote expertise and increase capacity by offloading some monitoring to remote teams. Unfortunately, the rapid deployment of telemedicine, especially TCC, is constrained by multiple barriers. In the summer of 2020, to support the National Emergency Tele-Critical Care Network (NETCCN) deployment, more than 50 national leaders in applying telemedicine technologies to critical care assembled to provide their opinions about barriers to NETCCN implementation and strategies to overcome them. Through consensus, these experts developed white papers that formed the basis of this article. Herein, the authors share their experience and propose multiple solutions to barriers presented by laws, local policies and cultures, and individual perspectives according to a minimum, better, best paradigm for TCC delivery in the setting of a national disaster. Cross-state licensure and local privileging of virtual experts were identified as the most significant barriers to rapid deployment of services, whereas refining the model of TCC to achieve the best outcomes and defining the best financial model is the most significant for long-term success. Ultimately, we conclude that a rapidly deployable national telemedicine response system is achievable.

New graduate nurse residency: a network approach.

Newly graduated RNs are the workforce of the future. The complex healthcare environment makes the transition from new graduate to competent RN challenging. A structured support system is essential to smooth the transition process. Nursing residency programs are well established in the literature as a mechanism of support. This article describes the implementation of a system-level new-graduate nurse residency across multiple facilities.

Applying a Military Teleophthalmology Mobile App in a Noncombat Emergent Care Setting.

INTRODUCTION: Teleophthalmology has a natural role in the military due to the inherent organization of its medical system, which provides care to patients in remote locations around the world. Improving access to ophthalmic care enhances force readiness because ocular trauma and disease can cause vision impairment or blindness and can occur anywhere service members are located. Recently, a secure, Health Insurance Portability and Accountability Act-compliant mobile phone application (app) for teleophthalmology called Forward Operating Base Expert Telemedicine Resource Utilizing Mobile Application for Trauma (FOXTROT) was beta tested in Afghanistan and demonstrated that this solution can improve and extend ophthalmic care in a deployed environment. There are few civilian or military teleophthalmology solutions for ocular trauma and disease in an urgent or emergent ophthalmic care setting. Civilian teleophthalmology solutions have largely been developed for disease-specific models of care. In this work, we address this gap by testing the FOXTROT app in a non-deployed, emergent care setting. MATERIALS AND METHODS: We evaluated the use of the teleophthalmology mobile phone app (FOXTROT) in a non-deployed military setting at the Malcolm Grow Medical Clinics and Surgery Center at Joint Base Andrews in Maryland. Consults from the emergent care center were placed by providers using the app, and the on-call ophthalmologist responded with treatment and management recommendations. The primary outcomes were response within the requested time, visual acuity tested in both eyes, agreement between the teleophthalmology and the final diagnosis, and the number of communication or technical errors that prevented the completion of consults. The secondary outcomes were average response time and the number of consults uploaded to the medical record. RESULTS: From October 2020 to January 2022, 109 consults were received. Ten consults had communication or technical errors that prevented the completion of consults within the app and were excluded from the analysis of completed consults. Of the 99 completed consults, responses were given within the requested time in 95 (96.0%), with the average response time in 11 minutes 48 seconds (95% confidence interval, 8 minutes 57 seconds to 14 minutes 41 seconds). Visual acuity was tested in both eyes in 56 (56.6%). There was agreement between the teleophthalmology diagnosis and the final diagnosisin 40 of 50 (80.0%) consults with both a teleophthalmology and final diagnosis. Ninety-eight (99.0%) consults were uploaded to the patient's medical record. CONCLUSIONS: Beta testing of a teleophthalmology mobile phone app (FOXTROT) in a noncombat emergent care setting demonstrated that this solution can extend ophthalmic care in this environment at a military treatment facility. However, improvements in the reliability of the platform are needed in future developments to reduce communication and technical errors.

Preserving Continuity of Behavioral Health Clinical Care to Patients Using Mobile Devices.

INTRODUCTION: The current model for treating behavioral health patients requires that providers and patients be in the same location for appointments. However, deploying warfighters present a challenge to this current model. Recent advances in technology make telehealth or virtual visits a viable option to replace the current model. This project leveraged mobile technology to see if performing tele-behavioral health visits presented a viable option to the current in-person model for future deployed warfighters. At the time of this publication, the authors note the current pandemic lends all the more urgency to the need for enhancing our video communication platforms for remote monitoring with the Military Health System. MATERIALS AND METHODS: The research team assessed existing Internet protocol-based desktop teleconferencing solutions, generically known as a Web Real-Time Communications (WebRTC) system, for establishing a secure connection to a Service Members personal mobile device outside of the Department of Defense (DoD) network. Of the five existing WebRTC systems evaluated, only the backbone component to the existing Defense Information Systems Agency Global Video Services (DISA GVS) known as Vidyo, was suitable to meet DoD security requirements and still connect with both major operating systems (OS) on mobile devices. An existing DoD program of record mobile application, mCare, was integrated with Vidyo desktop technologies to form what the research team called "Mobile Connect." RESULTS: Deployment of the Mobile Connect product yielded distinct differences and high levels or variability between the .osd.mil and the army.mil network connections over time. These network differences impacted quality of service solution where Mobile Connect could not be used to provide care between the .mil and patient's personal mobile devices from a osd.mil domain connection. The current DoD WebRTC systems offer potential solutions but presently cannot connect with personal mobile devices in their current configurations. Additionally, any WebRTC system used by the DoD for future connections to personal mobile device must leverage commercial Single Socket Layer certificates (e.g., not DoD issued), or the communications with the mobile device will fail as a result of an authentication error. CONCLUSION: It is technically feasible to provide desktop Video Tele-Conference capabilities from a .mil computer to a personal mobile device without compromising DoD security and information assurance requirements using future WebRTC systems. Approved ports, protocols, and system settings must be configured to accept both inbound and outbound, encrypted traffic to/from personal mobile devices to maintain consistent quality of service with all DoD networks. Of the current DoD WebRTC options, working with the DISA GVS Program Manager to expand services to support commercial mobile devices has the highest probability of future success.

Military Teleophthalmology in Afghanistan Using Mobile Phone Application.

IMPORTANCE: The coronavirus disease 2019 pandemic has highlighted the need to expand telemedicine solutions. OBJECTIVE: To beta test a secure teleophthalmology mobile app at military treatment facilities in Afghanistan. DESIGN, SETTING, AND PARTICIPANTS: This prospective case series included 16 military treatment facilities at diverse roles of care including forward operating bases in Afghanistan and 1 location outside of Afghanistan. Thirty point-of-care medics and medical professionals were included from September to November 2019. INTERVENTIONS: Users placed teleophthalmology consults on their mobile phone using the mobile eye care app, and an expeditionary ophthalmologist stationed at a military hospital in Afghanistan responded. Users graded the mobile app using a rating scale from 1 to 5, with 1 being very dissatisfied and 5 being very satisfied. MAIN OUTCOMES AND MEASURES: Mean initial response time, agreement between the teleophthalmology diagnosis and final diagnosis, treatment and management following recommendations outlined in the Joint Trauma System clinical practice guidelines, prevention of the need for aeromedical evacuation, user satisfaction, and security and the Health Insurance Portability and Accountability Act compliance of consult. RESULTS: There were 28 consults placed over 6 weeks by 18 different users that were received by the expeditionary ophthalmologist. The mean (SD) patient age was 30.3 (9.8) years. Most patients were male (26 [93%]) and active duty US military (22 [78%]). The mean initial response time was 3 minutes 58 seconds (95% CI, 2 minutes 30 seconds to 5 minutes 26 seconds). There was agreement between the teleophthalmology diagnosis and final diagnosis in 24 consults (86%; 95% CI, 72%-100%). The treatment and management followed recommendations outlined in the Joint Trauma System Clinical Practice Guidelines for Eye Trauma: Initial Care in 28 consults (100%). Teleophthalmology consultation prevented the need for aeromedical evacuation in 4 consults (14%; 95% CI, 0.7%-28%). The patient returned to duty in 15 consults (54%; 95% CI, 34%-73%). Median overall satisfaction was 5 (minimum, 3; maximum, 5). All 28 consults (100%) were secure and compliant with the Health Insurance Portability and Accountability Act. CONCLUSIONS AND RELEVANCE: While only a limited number of consults were evaluated, this study suggests that teleophthalmology mobile phone apps may improve and extend ophthalmic care in combat zones.

Starch-Flavor Complexation Applied to 2-Acetyl-1-pyrroline.

The pleasant popcorn-like smelling compound 2-acetyl-1-pyrroline (2AP) occurs naturally in many foods but is scarcely used as a flavoring agent due to its great instability. In this work, we evaluate the potential of high amylose corn starch to complex and stabilize 2AP. The methodology was first optimized using model compounds, 2-acetylpyridine and 2-acetyl-2-thiazoline, and then applied to 2AP. Complexes were successfully prepared and characterized using X-ray diffraction, gas chromatography, and differential scanning calorimetry. Loadings of up to 0.504 (±0.071)% 2AP were achieved, and storage studies showed that over half of the flavor was retained after 2 weeks at 0% relative humidity. To our knowledge, this is the first demonstration that 2AP can form amylose inclusion complexes and may lead to a method to effectively stabilize this labile aroma compound.

Does Mobile Care ('mCare') Improve Quality of Life and Treatment Satisfaction Among Service Members Rehabilitating in the Community? Results from a 36-Wk, Randomized Controlled Trial.

Introduction: Research has shown that mobile phones can help with management of numerous health problems. As an adjunct to care management provided to injured service members rehabilitating in their communities, particularly those with mild traumatic brain injury (mTBI), post-traumatic stress (PTS), and/or behavioral health problems, the Army developed a mobile phone application called "mCare." This study examined whether service members who received mCare had higher well-being, were more satisfied with their care, and viewed mCare as a valuable part of their care management as compared with their counterparts who received standard care management alone, and whether those with mTBI, PTS, and/or behavioral health problems benefited differently from mCare. Materials and Methods: In-processing service members at four community-based warrior transition units were recruited for participation in a 36-wk, randomized, controlled trial and allocated to receive standard care management plus mCare (n = 95) or standard care management alone (n = 87). Participants in the mCare group received daily questionnaires, tips, and appointment reminders. All participants were asked to complete the General Well-being Schedule (GWS) at baseline, 12, 24, and 36 wk, and the Case Management Quality Questionnaire (CMQQ) at 12, 24, and 36 wk. All participants and care managers were approached to complete interviews about the usability/likeability of mCare or standard care management. The analyses tested for group differences in completion of the intervention, graphed means for the GWS and CMQQ by group/subgroup, and statistically compared the longitudinal trends in these outcomes using mixed models in which group, time, and group*time were included as regression variables. The analyses also tallied interview responses and identified thematic quotes. The study protocol was reviewed and approved by the Walter Reed National Military Medical Center's Institutional Review Board. Results: Estimated rate of change in GWS scores was -2.2 (standard error = 1.0; t = -2.1; p = 0.0382). Estimated rate of change in CMQQ scores was -0.8 (standard error = 0.5; t = -1.52; p = 0.1299). Neither change was meaningful. Rates of change in the GWS and CMQQ scores did not differ by group or by behavioral health, mTBI, and PTS subgroups within the groups. The interviews found that 83% of mCare participants liked the communication with their care managers versus 73% of standard care management participants. Participants in both the mCare group and the care managers said that they liked the application's appointment tracking and reminders. Care managers thought mCare was particularly useful for people with mTBI, PTS, and cognitive problems. Conclusion: mCare did not result in differences in general well-being and satisfaction with care management among service members rehabilitating in their communities, some with mTBI, PTS, and/or behavioral health problems. But participants and care managers who used mCare said that they found it useful. Study limitations included the diversity of clinical issues of the participants, greater missing data among mCare participants, and the high baseline quality of care management in the settings observed. The fact that patients and care managers liked mCare, apart from no changes in outcomes, is important because health care is increasingly adopting mobile solutions.

Enhancing mHealth Technology in the Patient-Centered Medical Home Environment to Activate Patients With Type 2 Diabetes: A Multisite Feasibility Study Protocol.

BACKGROUND: The potential of mHealth technologies in the care of patients with diabetes and other chronic conditions has captured the attention of clinicians and researchers. Efforts to date have incorporated a variety of tools and techniques, including Web-based portals, short message service (SMS) text messaging, remote collection of biometric data, electronic coaching, electronic-based health education, secure email communication between visits, and electronic collection of lifestyle and quality-of-life surveys. Each of these tools, used alone or in combination, have demonstrated varying degrees of effectiveness. Some of the more promising results have been demonstrated using regular collection of biometric devices, SMS text messaging, secure email communication with clinical teams, and regular reporting of quality-of-life variables. In this study, we seek to incorporate several of the most promising mHealth capabilities in a patient-centered medical home (PCMH) workflow. OBJECTIVE: We aim to address underlying technology needs and gaps related to the use of mHealth technology and the activation of patients living with type 2 diabetes. Stated differently, we enable supporting technologies while seeking to influence patient activation and self-care activities. METHODS: This is a multisite phased study, conducted within the US Military Health System, that includes a user-centered design phase and a PCMH-based feasibility trial. In phase 1, we will assess both patient and provider preferences regarding the enhancement of the enabling technology capabilities for type 2 diabetes chronic care management. Phase 2 research will be a single-blinded 12-month feasibility study that incorporates randomization principles. Phase 2 research will seek to improve patient activation and self-care activities through the use of the Mobile Health Care Environment with tailored behavioral messaging. The primary outcome measure is the Patient Activation Measure scores. Secondary outcome measures are Summary of Diabetes Self-care Activities Measure scores, clinical measures, comorbid conditions, health services resource consumption, and technology system usage statistics. RESULTS: We have completed phase 1 data collection. Formal analysis of phase 1 data has not been completed. We have obtained institutional review board approval and began phase 1 research in late fall 2016. CONCLUSIONS: The study hypotheses suggest that patients can, and will, improve their activation in chronic care management. Improved activation should translate into improved diabetes self-care. Expected benefits of this research to the scientific community and health care services include improved understanding of how to leverage mHealth technology to activate patients living with type 2 diabetes in self-management behaviors. The research will shed light on implementation strategies in integrating mHealth into the clinical workflow of the PCMH setting. TRIAL REGISTRATION: ClinicalTrials.gov NCT02949037. https://clinicaltrials.gov/ct2/show/NCT02949037. (Archived by WebCite at http://www.webcitation.org/6oRyDzqei).

Formation of inclusion complexes between high amylose starch and octadecyl ferulate via steam jet cooking.

Amylose-ligand inclusion complexes represent an interesting approach to deliver bioactive molecules. However, ferulic acid has been shown not to form single helical inclusion complexes with amylose from high amylose maize starch. To overcome this problem a lipophilic ferulic acid ester, octadecyl ferulate, was prepared and complexed with amylose via excess steam jet cooking. Jet-cooking octadecyl ferulate and high amylose starch gave an amylose-octadecyl ferulate inclusion complex in 51.0% isolated yield. X-ray diffraction (XRD) and differential scanning calorimetry (DSC) confirmed that a 61 V-type inclusion complex was formed. Amylose and extraction assays showed the complex to be enriched in amylose (91.9±4.3%) and contain 70.6±5.6mgg(-1) octadecyl ferulate, although, minor hydrolysis (∼4%) of the octadecyl ferulate was observed under the excess steam jet-cooking conditions utilized. This study demonstrates that steam jet cooking is a rapid and scalable process in which to prepare amylose-octadecyl ferulate inclusion complexes.

Assessment of patient engagement with a mobile application among service members in transition.

OBJECTIVE: This article examines engagement with a mobile application ("mCare") for wounded Service Members rehabilitating in their communities. Many had behavioral health problems, Traumatic Brain Injury (TBI), and/or post-traumatic stress disorder (PTS). The article also examines associations between Service Members' background characteristics and their engagement with mCare. MATERIALS AND METHODS: This analysis included participants who received mCare (n = 95) in a randomized controlled trial. mCare participants received status questionnaires daily for up to 36 weeks. Participant engagement encompasses exposure to mCare, percentage of questionnaires responded to, and response time. Participants were grouped by health status-that is, presence/absence of behavioral health problems, PTS, and/or TBI. Histograms and regression analyses examined engagement by participants' health status and background characteristics. RESULTS: Exposure to mCare did not differ by health status. Participants usually responded to ≥60% of the questionnaires weekly, generally in ≤10 h; however, participants with behavioral health problems had several weeks with <50% response and the longest response times. Total questionnaires responded to and response time did not differ statistically by health status. Older age and higher General Well-Being Schedule scores were associated with greater and faster response. DISCUSSION: The sustained response to the questionnaires suggests engagement. Overall level of response surpassed trends reported for American's usage of mobile applications. With a few exceptions, Service Members engaged with mCare irrespective of health status. CONCLUSION: Mobile health has the potential to increase the quantity and quality of patient-provider communications in a community-based, rehabilitation care setting, above that of standard care.