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Are mobile health apps and digital interventions improving adherence?

Are mobile health apps and digital interventions improving adherence? | Patient Self Management |

Mobile and digital health’s potential to help bring about healthy behavior changes has led a number of companies to target the problem with new connected devices, applications, and services. Some of these have claimed to be highly effective: MediSafe recently stated that their app raised users’ adherence rate to 81 percent over the course of its first eight weeks that it was made available, and Vitality GlowCaps once reported pushing adherence rates to as high as 98 percent, both well above the World Health Organization average of 50 percent. NEHI has stated that digital health offerings similar to these have considerably improved adherence, but the market penetration for these tools is still low.


The challenge for these companies is not just to develop an effective product, but also to figure out who will pay for it. That means addressing the sticky question of whose problem med adherence really is.

 Patients don’t take their medication for a number of reasons. Forgetfulness is one, particularly in chronic disease patients who have a large regimen of pills to keep track of and in elderly patients who may have poor memories or become confused easily. But other patients don’t take their meds for psychological reasons: some patients “feel fine” and skip a drug, some are concerned about real side effects. Some, according to NEHI Senior Health Policy Associate Nick McNeill, are concerned about imagined side effects. Finally, many patients stop taking medications because they simply can’t afford the co-pay. This, of course, is not a complete list but it does include some of the more commonly referenced reasons. Digital health could play a role in resolving some of them.

Via Andrew Spong
rob halkes's insight:

Indeed, it is due to a lot if still unknown and  scarcely reserached personal reasons that influence adherence to therapy. More must be done!

Andrew Spong's curator insight, January 21, 2013 12:08 PM

Click on the title link above to read the full article on mobihealthnews

Jenni Lawrence's comment, January 22, 2013 10:46 PM
cost of taking now versus BIGGER costs of not taking now.... hmmm... seems like a no brainer to me!
Keith McGuinness's curator insight, September 18, 2014 8:50 PM

This is moving in the right direction.  Measure the change in health brought about by the app.  The patient will learn why taking the meds is helpful, and the physicians can embrace this kind of evidence.

Once a developer understands the mechanisms (within the app) that drive the desired change in health metrics, he/she can focus product design efforts on driving patients toward those mechanisms.  

Patient Self Management
patient self management, compliance, adherence, patient coach, patient monitoring, patient empowerment, shared decision making, patient education, patient counseling, participatory care
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Big BMJ supplement on Patient Centred Care – with many SPM and MedX voices |

Big BMJ supplement on Patient Centred Care – with many SPM and MedX voices | | Patient Self Management |

By ePatient Dave:
This is a great week for Society of Participatory Management (SPM), for our colleagues at the Stanford Medicine X conference, and for everyone else who's been working for years to shift medicine's
I’m thrilled to say that the BMJ, formerly the British Medical Journal, has just released a new article I wrote about the “social movement” aspect of our work, including the rationale for listening to the patient perspective.

Intended for medical audiences around the world, it’s part of a big, 21-article multimedia “Spotlight” supplement that will be in Thursday’s print edition; it was all released online yesterday. Over on the e-patient blog I posted the full list of articles, including the names of other members of our Society for Participatory Medicine who are in this issue. Big participation, big visibility!

This supplement, appearing in one of the world’s top medical journals, may well be the biggest moment yet in the history of our movement. It’s got hours of reading and listening, with contributions from eight countries, if I counted correctly.

Those of you in my generation – the era of many social movements – will relate to the parallels with what’s happening today: a whole class of people whose voice has been considered “not worthy” is speaking up, demonstrating capability, and pushing back when we’re told to “stay in our place.” :-)

rob halkes's insight:

The new era of health care is to be build around these principles:

- Multidisciplinary connected,
- Integrated,

- participatory care, and,

- eHealth

Participatory care is about patient empowerment, not only by principle but also by effectiveness. And, beyond that, it is also from a finance argument that active, guided, but self-managing patients will lead to better health outcomes and less costs.

Lots of health care systems, governments and payors must reflect to find approaches of development that are constructively aiming at building the new structures of health care with parallel reasonable and attainable efforts in lowering budgets, instead of enforcing costs cuts that initiate panic and non desirable effects.

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Medical errors: We can't trust doctors to get it right

Medical errors: We can't trust doctors to get it right | Patient Self Management |

We have lost track of what should be the most important dictum in medicine, his "First, do no harm."

“If doctors do no other good, they at least prepare their patients early for death, undermining little by little and cutting off their enjoyment of life.”

These words from Montaigne are 350 years old, but, sadly, too often they describe the results of modern medicine, particularly when it is mindlessly applied in a needlessly heroic way to the end of life.

I spend a lot of time going around to different places warning professionals and the public that overdiagnosis, overtesting, and overtreatment are bad for our health.

Recently I have been witnessing these dangers firsthand. I have a friend who has lung cancer — the “good,” slow-growing kind. His doctors have been less kind than the cancer. They keep screwing up in ways that seem likely to kill my friend before his cancer does.

The basic problem is that modern medicine consistently violates the ancient advice of Hippocrates: “It is better to know the patient who has the disease than the disease the patient has.”

My friend has a small army of very highly specialized doctors all treating lab results in one tiny medical domain while ignoring all the aggressive stuff the other specialists are doing. None of the doctors has a global picture of my friend’s treatment and the specific risks and benefits that apply to each new test or treatment.

The result is dangerous medical chaos. Doctors love pictures and get paid a lot for ordering and reading them. Over the years my friend has been subjected to countless and mostly unnecessary imaging studies with contrast dyes that have compromised his kidneys. It seems likely that renal insufficiency will kill him before his lung cancer does. He is also no longer eligible for additional lung-cancer treatments because his kidneys flunk protocol requirements. And along the way he has been prescribed several unnecessary medications that also hurt his kidneys. Everyone focused on the lung cancer; no one noticed the harm they were doing to the kidneys.

There have also been several close calls because he was prescribed multiple medicines by multiple doctors without coordination and due consideration of the drugs’ interactions and synergistic harms.

The mistakes were all easily preventable if anyone were minding the store and paying attention to the patient, not the lab tests. In any common-sense world doctors would care about risks and harms and wouldn’t always be rushing to order stupid and dangerous tests and treatments.

.. Read on in the original bog!

rob halkes's insight:

Everyone will have some example of how things can go wrong. or say less then well in care for health ... 

It is my own conviction that patients need to be assertive first, not just health literate. Professionals are professionals while they have  taken up the task to help and support patients with their conditions. First to that is explaining what they suggest and making sure the patient understands.. -

Just like you just can't expect a teacher to be ineffecive with pupils not knowing what they teach. -  In education that's a fact to start with..!

In health care, one cannot start from the fact that patients know what they have as a condition....

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Launch of first ever Health App Toolkit to help people understand and use health apps

Launch of  first ever Health App Toolkit to help people understand and use health apps | Patient Self Management |

From Patient View:

Launch of the first-ever toolkit to help people understand and use health apps
©PatientView Ltd 2014
Author: Tony Newbold
Editors: Clive Nead, Dee O’Sullivan, Alexandra Wyke
Designer: Mark Ansell

A clear, concise, simple manual to help patients and the public make the best choices and decisions about health apps, “Health Apps—a Toolkit to Help You”, is available in print and online. Launched today, Wednesday, 1st October 2014, at the European Health Forum Gastein 2014, and circulated to the Forum’s 650 delegates (who come from all over Europe and beyond, and who represent the key stakeholders of the European health policy community).

This Toolkit is needed to answer the many questions that patients and carers have about health apps
A soon-to-be-published study* by PatientView will reveal that the public are confused by the sheer number of health apps available (100,000), and are not sure that a particular health app will help them. Members of the public may also not trust health apps, because they do not know who makes the apps, or whether their health data would be secure on an app.

[*Source: “What do patients and carers want from health apps?” A July-October 2014 global survey of over 1,000 patients, conducted by PatientView in collaboration with Health 2.0. Survey results to be released Monday, 10th November 2014, at the 2014 Health 2.0 conference in London.]

“The myhealthapps’ Toolkit is a good initiative to empower citizens. It is the type of health-literacy project that the European Commission encourages.”

—Robert Madelin, Director General, DG CONNECT, European Commission

rob halkes's insight:

The first, researchbased toolkit for patients to help them select their health apps! Insightful and practical! See it online here

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Co-Creating Healtcare | Sustania - building the world of tomorrow

Co-Creating Healtcare | Sustania - building the world of tomorrow | Patient Self Management |

In Sustainia, the most important resource in the sustainable transition is you. In the guide to person-centred care, we have taken a closer look at the world’s healthcare systems and what it takes to make them person-centred.

What we understand by healthcare today needs to be redefined so that you become an active partner in creating health.

DNV GL and Sustainia are travelling the world this fall to explore how we can co-create healthcare.

The mission is to put the person, you, at center of the care. And to do this, we will identify, document and communicate solutions that can inspire a safer, smarter and more sustainable healthcare approach.

rob halkes's insight:

Sustania's inititiative is a great one to move people in health care to actually do some and relate with others to comparte and learn, how to do this. Implementation is key, as they say. And, it is. read on their website all about it.

As for the method of co-creating health care, this might help:

co-creating in health care !

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The Doctor’s Inbox — Healthcare Providers Use Technology to Communicate with Patients

The Doctor’s Inbox — Healthcare Providers Use Technology to Communicate with Patients | Patient Self Management |

Despite security and privacy concerns, a growing number of physicians are embracing digital technology in their communication with patients. That includes sharing information about services and wellness to a broad audience, and also corresponding directly with patients about their personal health issues.

The recent improvements start with physicians revamping their websites. This has allowed doctors to post essential information about which services they offer and to make appointment scheduling easier through patient portals. That includes streamlining the processes of rescheduling and sending reminders electronically instead of over the phone.

A common analogy that’s made is making the patient scheduling process similar to picking a seat for a flight through an airline’s website, says James Karpook, principal at The Chartis Group.

That mentality is expanding to include information about how to contact physicians directly to follow-up after an office visit.

“More and more physicians are communicating with their patients via email so that they don’t have to call in and be waiting on the phone to speak to a nurse or the physician,” says Karpook.

Another area where communications technology is helping doctors is in disease management. For example, patients who have congestive heart failure can use a device at home that links to a processor to capture real-time results. Physicians can then take immediate action when a problem arises.

Also, diabetes patients are using mobile apps to log their blood-sugar levels so healthcare providers can monitor them in real-time. Providers are also sending patients text message reminders to check their blood sugar and then have the data sent to the doctor’s office.

Social media is another growing digital frontier for physicians. Many are posting articles and sharing their expertise about wellness and healthcare innovation on Facebook, Twitter, and LinkedIn. “Social media is ideal to connect with patients collectively, but not individually,” said Dr. Kevin Pho to The Doctor’s Tablet Blog.

Dr. Pho is an advocate of doctors having protected social media time during the workday so they can write blog posts or create videos to be shared. That would force them to get more comfortable with the technology and possibly push ideas to another level. “Replacing a half-day session a week of seeing patients with social media time to create content would be a reasonable goal,” he said. “Healthcare leaders and administrators are the ones who can make that happen.”

Still, it’s the one-on-one electronic communication that will set the tone for the future of healthcare. More doctors are corresponding with patients through email and text messaging. Karpook also cites a next wave of physician concierge services that charge a monthly fee to allow patients greater access to physicians through email, instant messaging, or video chat. Making these channels secure and private is the biggest challenge ahead.

 “We’ll have to continue to find ways to ensure that electronic health information that’s shared is secure,” he says. “There needs to be the IT infrastructure to support it.”

To a great extent, electronic communication between doctors and patients will be driven by consumer preference. As more consumers begin to prefer electronic means for communication, healthcare organizations and physicians will have to adapt to accommodate them. Couple that with the bigger structural healthcare reforms that are promoting better communication between doctors and patients, and it’s likely that we’ll be seeing more progress in this area very soon.

“Perhaps in the coming years, when payment isn’t tied to the number of patients seen, communicating with patients can be emphasized, whether it’s through a phone call, email, or social media,” said Dr. Pho.

Via Plus91
rob halkes's insight:

Yes, the world of medicine and physicians is changing ;-)

Lisette Pangilinan's curator insight, August 23, 2014 2:57 AM

Social media plays an important role in promoting health care and wellness. We are now empowered to take a role in our own health.

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Wolters Kluwer | Press | News | Survey: Americans Want Greater Control Over Their Own Healthcare

Wolters Kluwer | Press | News | Survey: Americans Want Greater Control Over Their Own Healthcare | Patient Self Management |
Wolters Kluwer is a market-leading global information services and publishing company focused on professionals.

(December 12, 2012)  — 

Philadelphia, PA (December 12, 2012) – According to a new Wolters Kluwer Health survey, 80 percent of consumers believe the greater “consumerization” of healthcare – or the trend of individuals taking a greater and more active role in their own healthcare – is positive for Americans. Survey data suggests many Americans feel that a greater role in their care is not only good, but necessary, with 86 percent of consumers reporting that they feel they have to take a more proactive role in managing their own healthcare in order to ensure better quality of care.


Most consumers also say they feel prepared to take on a greater role in managing their own healthcare, with 76 percent reporting that they have the information and tools to take a more proactive role in healthcare decisions ranging from choosing healthcare providers to researching treatment options. Despite feeling prepared, only 19 percent report that they have their own electronic Personal Health Record (PHR).


“With greater responsibility placed on patients to take a role in their own care, it’s essential that consumers have access to evidence-based tools and resources to make informed decisions about their care in partnership with their healthcare providers,” said Dr. Linda Peitzman, Chief Medical Officer, Wolters Kluwer Health. “Access to research-based medical information not only can positively impact quality of care, but it also can lead to improved doctor-patient communication and relationships.”

Survey findings showed that the notion of the “patient experience” is also gaining significance for many Americans. Three in ten adults (30 percent) want their patient experience to be the same as any other customer experience they have – such as shopping, hotel and travel experiences – complete with choices and control.


See report here

rob halkes's insight:

Already at the end of 2012 this survey was completed about the consumerization of health care. See the report here .

Now, in 2014, we can state that the trend is persevering.

Ehealth is now no more option, it is a must tp adapt to patients' wishes!

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Co-Creation in Health Care

Co-Creation in Health Care | Patient Self Management |

Experience co-creation in health care is an effective method to innovate value to patients in a personalized way, in collaboration with all relevant stakeholders.
It is intended to benefit patient...

rob halkes's insight:

Co-creation between all stakeholders in health care is certainly necessary to create sound and proper patient journeys in ehealth.

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Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: A survival analysis model

Effects of diabetes self-management programs on time-to-hospitalization among patients with type 2 diabetes: A survival analysis model | Patient Self Management |

Patient Education and Counseling, Volume 95, Issue 1, Pages 111-117, April 2014, Authors:Omolola E. Adepoju; Jane N. Bolin; Charles D. Phillips; Hongwei Zhao; Robert L. Ohsfeldt; Darcy K. McMaughan; Janet W. Helduser; Samuel N. Forjuoh

Abstract Objective

This study compared time-to-hospitalization among subjects enrolled in different diabetes self-management programs (DSMP). We sought to determine whether the interventions delayed the occurrence of any acute event necessitating hospitalization.


Electronic medical records (EMR) were obtained for 376 adults enrolled in a randomized controlled trial (RCT) of Type 2 diabetes (T2DM) self-management programs. All study participants had uncontrolled diabetes and were randomized into either: personal digital assistant (PDA), Chronic Disease Self-Management Program (CDSMP), combined PDA and CDSMP (COM), or usual care (UC) groups. Subjects were followed for a maximum of two years. Time-to-hospitalization was measured as the interval between study enrollment and the occurrence of a diabetes-related hospitalization.


Subjects enrolled in the CDSMP-only arm had significantly prolonged time-to-hospitalization (Hazard ratio: 0.10; p=0.002) when compared to subjects in the control arm. Subjects in the PDA-only and combined PDA and CDSMP arms showed no improvements in comparison to the control arm.


CDSMP can be effective in delaying time-to-hospitalization among patients with T2DM.

Practice implications

Reducing unnecessary healthcare utilization, particularly inpatient hospitalization is a key strategy to improving the quality of health care and lowering associated health care costs. The CDSMP offers the potential to reduce time-to-hospitalization among T2DM patients.

rob halkes's insight:

Focused and systematic self management programs work! Hopitalization maybe prevented. Inspiring reading.

ALSO: the image I used came from the "Arthritis Ireland" Project: "the case for self management" see here:

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Web 2.0 Chronic Disease Self-Management for Older Adults: A Systematic Review

Web 2.0 Chronic Disease Self-Management for Older Adults: A Systematic Review | Patient Self Management |
Web 2.0 Chronic Disease Self-Management for Older Adults: A Systematic Review

Background: Participatory Web 2.0 interventions promote collaboration to support chronic disease self-management. Growth in Web 2.0 interventions has led to the emergence of e-patient communication tools that enable older adults to (1) locate and share disease management information and (2) receive interactive healthcare advice. The evolution of older e-patients contributing to Web 2.0 health and medical forums has led to greater opportunities for achieving better chronic disease outcomes. To date, there are no review articles investigating the planning, implementation, and evaluation of Web 2.0 chronic disease self-management interventions for older adults.
Objective: To review the planning, implementation, and overall effectiveness of Web 2.0 self-management interventions for older adults (mean age ≥ 50) with one or more chronic disease(s).
Methods: A systematic literature search was conducted using six popular health science databases. The RE-AIM (Reach, Efficacy, Adoption, Implementation and Maintenance) model was used to organize findings and compute a study quality score (SQS) for 15 reviewed articles.
Results: Most interventions were adopted for delivery by multidisciplinary healthcare teams and tested among small samples of white females with diabetes. Studies indicated that Web 2.0 participants felt greater self-efficacy for managing their disease(s) and benefitted from communicating with health care providers and/or website moderators to receive feedback and social support. Participants noted asynchronous communication tools (eg, email, discussion boards) and progress tracking features (eg, graphical displays of uploaded personal data) as being particularly useful for self-management support. Despite high attrition being noted as problematic, this review suggests that greater Web 2.0 engagement may be associated with improvements in health behaviors (eg, physical activity) and health status (eg, HRQoL). However, few studies indicated statistically significant improvements in medication adherence, biological outcomes, or health care utilization. Mean SQS scores were notably low (mean=63%, SD 18%). Studies were judged to be weakest on the Maintenance dimension of RE-AIM; 13 reviewed studies (87%) did not describe any measures taken to sustain Web 2.0 effects past designated study time periods. Detailed process and impact evaluation frameworks were also missing in almost half (n=7) of the reviewed interventions.
Conclusions: There is need for a greater understanding of the costs and benefits associated with using patient-centered Web 2.0 technologies for chronic disease self-management. More research is needed to determine whether the long-term effectiveness of these programs is sustainable among larger, more diverse samples of chronically ill patients. The effective translation of new knowledge, social technologies, and engagement techniques will likely result in novel approaches for empowering, engaging, and educating older adults with c

rob halkes's insight:

Great inspiring review of self management interventions using web20 applications. Surely more research is needed. But let it inspire you to contribute! 

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Health apps: where do they make sense? A patient opinion-informed white paper

Health apps: where do they make sense? A patient opinion-informed white paper | Patient Self Management |

Conclusions of the first ever cross-stakeholder, pan-european seminar on health apps, held at the King's Fund on 28 October 2013.


The five key messages:


1. Overhauling healthcare systems–making them patient-centric

2. Engaging doctors in the prescribing of health apps
3. Overseeing quality standards for health apps
4. Ensuring that health apps remain of a high standard throughout their lifetime
5. Considerations for policymakers wishing to oversee health apps

Via Andrew Spong
rob halkes's insight:

Great Read!

Andrew Spong's curator insight, March 18, 2014 5:17 AM



1. Lip-service has been given to this idea since time immemorial, but there are few examples of such change having not only been instantiated, but maintained, and used to drive strategic direction. This is a systemic problem which I don't think will be resolved until we accept that 'reskinning' existing structures is inadequate to the needs of truly patient-centred healthcare design.


2. Unenforceable, but necessary. A paradox that may only be resolved through cross-constituency digital peer-review (imagine the degree of insight and involvement if there were a '#FOAMed meets #bcsm' for every disease area)


3. See above. 'Regulation' as we understand it will neither be viable, nor enforceable. Whether we want a 'top layer' of heavy-hitting health faculty acting as a secondary filter before content enters the App Store (Apple) and Play (Google) is another question. I'm not sure if it's even a good idea (re-replacing 'evidence with eminence' again) unless it's largely automated using a Watson-like AI with a complete picture of the existing gold standard in all evidence.


4. Predicated upon the expectation that they're of a high standard at launch, which simply isn't the case.. The majority of health-related content available as apps is of low quality and relevance.


5. Re. the first paragraph of the synopsis of this section: 'The consensus at the seminar was that the adoption of smartphone technology will not create health inequalities, but rather can increase healthcare sustainability'. I strongly agree with this line of reasoning, and feel that the 'digital divide' debate needs to be answered once and for all.


My answer to this last point: principally, this is a period of transition, and no plans should be made to accommodate perceived (and usually unsubstantiated) inequalities in terms of access to health information which will diminish over time -- although NB levels of health literacy are another matter. Where digital exclusion exists (and such conclusions often overlook the 'one step removed' access to digital health via family members, friends, and carers) the savings made from the efficient implementation of lower-cost digital health initiatives (and there really should be some; if there aren't, questions need to be asked about the organisation under review) should be reinvested in targeting hard-to-reach communities in an offline setting.

Marisa Maiocchi's curator insight, March 21, 2014 2:55 PM

Aportes y conclusiones del primer seminario pan-europeo sobre apps de salud. Muy interesante.

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Why I tweet: A patient advocate view

Why I tweet: A patient advocate view | Patient Self Management |
Who would have thought that this tiny aperture -- a mere 140 characters -- could connect me with so many smart, feisty people?


Since 1992, I have advocated for all of us to have the information, support and guidance we need to act to improve our health and get the most from our health care. I believe — and there is evidence to back me up — that we do better when we participate in our care to the extent we are able with as much knowledge about what might work that we can absorb.

As someone who has been/is being treated for five different types of cancer, I am familiar with many of the challenges we face in getting the most out of our health care. We not only need to know about our specific diseases and treatments and what we can do about them, but we also need to know something about how our care is organized and about changes in general health knowledge and medical practice that affect how we make use of the resources and services available to us. Then we have to act on our own behalf or on behalf of our child, partner, spouse or parent. The organization I direct, the Center for Advancing Health, has mapped out the tasks that are now ours — the many actions we must take to find good health care and benefit from it.

Every weekday, I tweet a carefully chosen stream of new evidence, analysis and commentary that covers all the health and health care angles that we — sick or well — might need to know about. I tweet material from major news outlets, peer-reviewed literature, blogs and magazines in the belief that thoughtful consideration of emerging information and understandings about health and health care will serve us well.

Here’s why I tweet what I tweet:

  • It has never been more important for us to be well-informed about so many aspects of health care — not just our complaint of the moment. Otherwise, when we are passive recipients of care, we risk being on the receiving end of medical errors, spending money on unnecessary tests, receiving suboptimal care or simply not knowing how we can best help ourselves. I aim to tweet what we need to know.
  • Evidence has never been more important. Especially considering media reports that much of the care we receive may not be consistent with evidence of what is currently deemed most effective. Combined with the rapid pace of new findings, understanding the facts relevant to your situation can be intimidating to patients and health professionals alike. Plus, it’s time-consuming for us to sort out solid information from broad assertions and slick advertisements, so I aim to tweet evidence worth noting, with the understanding that next week’s evidence may reverse what we know today.
  • Finding high-quality analysis and commentary that is relevant to the decisions we must make about our health and care every day is a bear. I know. I wouldn’t be traipsing through 40+ different sites every day in search of the best pieces if they were located in one place. I aim to tweet links to useful, diverse analyses and findings.
  • Understanding health and health care is not just a matter of digesting new facts. It also includes considering implications of those facts and different perspectives on policies so that the facts have context and meaning. I aim to include articles that tweak easy assumptions, shed light in dark corners and sometimes make me smile.
  • Lastly, it’s funner than heck to do this. I have an insatiable taste for gossip, a fascination with trying to figure out what we really need to know to care for ourselves, a long memory for ineffective-but-nevertheless-repeated health care foibles and an impulse toward snarkiness that occasionally breaks through. Spending a couple of hours each day trawling online for new findings, blogs, articles and essays that I think you might find interesting is a great way to start the day. ...
rob halkes's insight:

Thanks Jessie for sharing this. The only thing I can prudently verb, is: I wished doctors would do so, like you do.. ;-)
But I guess they don't .. ...

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It's Not Easy to Engage Patients — Even for ACOs

It's Not Easy to Engage Patients — Even for ACOs | Patient Self Management |

by Molly Gamble  - [ See my comment, if you want it quickly read - but that would be a shame ;-) ]
Patient-centered care is a cornerstone of any accountable care organization, but creating or joining one doesn't necessarily make patient engagement any easier. In the world of healthcare business, patient engagement may sound like a "soft" concept, but its difficulty is nothing to underestimate.

David Muhlestein, PhD, director of research at Leavitt Partners in Salt Lake City, says a minority of patients want to be engaged with their care teams in actively managing their healthcare. The high majority — likely approaching 70 percent — want to turn their care over to their physician and have them take the reigns. The rest of patients do not want to share decisions about their healthcare with physicians at all — they prefer to decide on their own.

"ACOs are finding it's really hard to get people engaged," says Dr. Muhlestein. "Some are proactive or are really trying to engage patients in different ways, but they're not particularly seeing more success than anyone else."

What is working for ACOs' patient engagement? What are the biggest roadblocks? As it turns out, there are several definitions of patient responsibility, high-deductible health plans are bad news for accountable care and no ACO provider will be successful on a high horse.

Seven degrees of engagement
There are numerous buzzwords for patient responsibility — patient engagement, accountability, skin in the game. It's easy to lump these ideas together as synonymous, but Dr. Muhlestein says there are some nuances.

For example, patients and physicians may arrive with different expectations for patient engagement. Patients see it as shared decision-making, or talking to a physician before a decision is made about their treatment to learn about the pros and cons, then making the ultimate decision in conjunction with the physician. It's a behavior largely reserved for the visit to the physician.

Physicians, on the other hand, see engagement as active condition management. This includes lifestyle changes, adherence to medications and regular dialogue with the care team to ensure the care plan is going smoothly. Essentially, this version of patient engagement involves the patient taking on more responsibilities that traditionally belonged to clinicians and carrying them out between physician visits.

People who have used accountants to complete income taxes may see where patients are coming from. Instead of doing a few tasks on a daily basis, many people find it easier to drop off their financial paperwork and receipts at the end of the year and let someone else do the math. The same is often true for patients' expectations for healthcare.

"You want to say, 'Here, you deal with this. I'll come back next month and you'll tell me how to change the doses of my meds,'" says Dr. Muhlestein.

How having "skin in the game" could muddle accountable care
There's another shade of patient responsibility, one that is a little greener in hue. More patients are taking on more financial responsibility for their healthcare. Recent years have brought a boom of high-deductible health plans, which cut businesses' health benefit costs by shifting more responsibility onto their employees. This is not the best news for people trying to advance accountable care. Some ACO leaders simply call these health plans outrageous, even immoral.  

"It's something we're concerned about," says Marcia Delk, MD, chief quality officer with Marietta, Ga.-based WellStar Health System, a five-hospital system participating in the Medicare Shared Savings Program. Dr. Delk spoke about the trend more generally, as high deductibles don't pertain to Medicare beneficiaries. "Those individuals with more of a responsibility to their bills are very price sensitive to whatever healthcare they're buying." And this sensitivity extends to basic preventive care — a huge component of population health — that is covered by their plans.

A 2012 study conducted by Rand Corp., Towers Watson and the University of Southern California examined families' use of care in the first year after switching from traditional plans to high-deductible health plans. These families spent, on average, about 14 percent less on their healthcare than those enrolled in traditional plans. But they also cut back on beneficial preventive services — such as cervical and colorectal cancer screenings, mammograms, and blood tests for glucose and lipids — even though most of these preventive services are covered under consumer-directed plans…
Much like the financial case providers must make for investments in population health management — linking initial costs to long-term gains — physicians and care teams may need to take a similar approach with their patients. Robust communication and patient education can help them understand the value of their vaccinations, mammograms and other preventive measures, and how these are not the measures to skimp on.

"If we engage patients properly and work with them to understand the benefit of taking care of a chronic condition, or getting a colonoscopy, and how that will reduce costs later on, it can work," says Dr. Delk.

Reaching instead of preaching
That seems to be the main job description for ACOs today — finding what works.

The normal fee-for-service environment does not have financial rewards for patient care coordination or care management programs. Even though ACOs are one of the most progressive steps toward pay-for-performance reimbursement, joining one doesn't necessarily provide direct reimbursement for patient education and engagement.

rob halkes's insight:

This blog describes how patient centered care and empowerment of patients is interpreted not so much as facilitating patients to take responsibility for their own care for health, supporting them to make right decision by dialogue about it and helping them to implement behavioral consequences in daily practice/therapy, but to shift responsibility all together to the patient, and just take only financial consequences ahead of whatever patients will do. As if they confront patients with what they really like to do: “Never mind me anymore, you just have to see by yourself now. And, in any case I’ll shift the financial consequences already to you to begin with!”
Indeed, for much of new approaches to design patient care we still have to find out. But that is the right attitude to invest in lowering cost for the future.
Self management in patient care is not a miracle to health care costs it is just the right journey to better times!

rob halkes's comment, January 31, 2014 4:08 AM
Thx all for sharing!
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ON medical consult: "Golf, Death, Sharing and Caring" - Howard J. Luks, MD

ON medical consult: "Golf, Death, Sharing and Caring" - Howard J. Luks, MD | Patient Self Management |

As I sat next to him, and now in a voice confident and ringing with anticipation, Mr A explained in painstaking detail how he determined which approach shot to hit to the 2nd green on the Black Course at Bethpage State Park.

Only 10 minutes earlier when Mr A and I first met he was weary, his face was drawn, and the sound of the aortic balloon pump keeping him alive made it nearly impossible to hear him.

Sitting down, which would seem like one of the simplest things to do, is the least practiced of five communication skills for doctors that Lenore would have endorsed and that research has shown can make a big difference in patient satisfaction.

“5 Simple Habit to Help Doctors Connect with Their Patients”

When my grandmother was caring for my ill grandfather — she expressed neverending confidence in his physician.  As a physician in training I was very interested about the qualities she saw in him that made her so confident that he was in fact the best doctor for her husband.

He talks to us.  He sits with us.  He takes time out of his busy day to let us know that he cares…

My grandfather passed away not too long after that discussion.  Sadly it was likely that very same physicians fault.  But no one needed to now that… my grandmother’s confidence didn’t wane through his last dying days.

(read on at the original blog by Howard..!)

rob halkes's insight:

On Medical Consult: great insight and vision on how consults might become truly interactive dialogues. Thanks Howard!

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New Website on Medications: Iodine

New Website on Medications: Iodine | Patient Self Management |

- Find what works - information about medications

from medical experts - and people like you.

Side effects, reviews, tradeoffs, and tips about thousands of drugs, built from clinical research and real life experience from people like you.

The database, which launched In September last, uses Google surveys to get consumer information on a wide variety of both over-the-counter and prescription drugs.

Users can search a specific drug from Aleve to Xanax and see how people generally feel about its efficacy, about the side effects from actual users, tradeoffs, comments from users, warnings, costs, and a readable versions of the drug’s package insert.

Iodine uses Google Consumer Surveys, of which they have 100,000 ones completed, and they add to their website every day. Iodine also uses data from clinical research, pharmacist surveys, adverse event reports made to the Food and Drug Administration (FDA) and the National Average Drug Acquisition Cost (NADAC)–which reports the average wholesale price pharmacies pay for over 20,000 drugs.

See also here and here

rob halkes's insight:

"Iodine" looks like a sharp curator of information on Medications.

It is actually a database on information about medications both from the research/medical site and from the users/patients' site: experiences and opinions. In the presentation of the data, there is a  partition between sources of information.

It's just only English and US based. A nice example to what is possible on information about medication to users!

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Data for health - Blog by Susannah Fox

Data for health - Blog by Susannah Fox | Patient Self Management |

Last week I was part of the first community meeting for Data for Health, a program sponsored by the Robert Wood Johnson Foundation. It was held in Philadelphia on October 30 [..].

You can catch up on the #data4health tweets thanks to Symplur — and there were some good ones [..]

Once again I was struck by how wide open the definition of “data” can be. I shared the following data points, based on a Pew Research study I led:

  • 7 in 10 U.S. adults track a health indicator for themselves or someone else.
  • Half track regularly, half track when something comes up.
  • Technology plays a minor role — about 1 in 5 trackers use a medical device, an app, or any other digital tool.
  • 1 in 3 trackers uses paper and pencil to take notes.
  • Fully half of trackers say they do so in their heads (and that includes me).
  • 1 in 3 trackers share their data with family members or clinicians, but many do not. They are asking secret questions and we must not only respect that, but build it into our planning.
  • 45% of U.S. adults live with a chronic health condition; of those, 8 in 10 track some aspect of health.
  • Tracking data is not a hobby for this group, but rather a way to see themselves more clearly. This might be true of public health in general — data is a mirror we try to use to make good decisions, based on facts.


My favorite insight of the day came from someone who, when discussing who should be part of the design process for health data systems, said that front desk workers are the ones who know the community best.

Read the full blog here !

ALso be sure to see the Pew study here

rob halkes's insight:

Indeed, so many people do track some health parameters themselves: the "ground" for many interest in health apps. But when it comes to relate with these data to their "formal" health care providers, .. we get into a complete other realm. It seems even to be so that patients try to avoid this exchange. .. So many things need to be accommodated at the site of the ...

indeed, the providers, of course.
One of the implications of ehealth.
(see for instance here )

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The Wearable Future: Will Consumers Make the Move Soon?

The Wearable Future: Will Consumers Make the Move Soon? | Patient Self Management |
Is that an app you're wearing or are you just happy to track your progress? This adulteration of Mae West's classic come-on is most likely justified.

Just Just recently, International Data Corporation issue the prediction that wearable device shipments worldwide would rise more than 488.9 percent between 2014 and 2018, rising from 19.0 million to 111.9 million.

It’s a rapidly changing marketplace.

“There’s been talk recently about the future of notifications on such devices, fashion brands such as Tory Burch and Diane von Furstenberg (DVF) have partnered with tech companies to make wearables more stylish, and GE is testing Google Glass to see how the technology could help boost efficiency in its car factories,” reports eMarketer.

So far, it appears that people like using mobile health and fitness apps to get in shape — and that wearables will be the next rung on the ladder.

Polling by Makovsky Health and Kelton Research in March documented high interest in wearable health and fitness devices: 81 percent of U.S. internet users said they would use one. Tracking fitness was the top reason, cited by 48 percent. Monitoring personal health issues came in second, and tracking diet and nutrition ranked third.

But developers could be waiting a while before the trend becomes widely accepted. A June, 2014 Opera Mediaworks study showed that only 2.5 percent of smartphone users said they used wearable fitness and activity trackers while exercising. Wearables may be the future, but “do-all smartphones are still No. 1 when exercisers need to pump it up,” eMarketer asserts.

rob halkes's insight:

Insiders in patients' preferences are prudent in asserting patients' wilingness to use health applications. It is suggested that patients like best those mhealth apps and/or wearbales that they "can keep to themselves", without 'formal' oversight by professionals or their physicians. For the time being it seems they want to be sure that their data are shared at that moment they themselves decide to do so. This also explains patients' reservations to spontaneously use PHR ro demand insight into their EHR's. Sharing needs trust.

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10 Lessons From Empowered Patients - USNews

10 Lessons From Empowered Patients -  USNews | Patient Self Management |

They've been there – and here's what you can learn from their experiences.

It’s your body – your tests, your treatment.

Your disease. But grasping control of your patient experience, when you’re surrounded by white coats and intimidating medical lingo and scary diagnoses, can be hard. U.S. News talked to 10 people who have a lot of experience being patients – or have advocated for a patient – about the most important lessons they’ve learned about patient empowerment. Their responses:

  • AnneMarie Ciccarella
  • Trisha Torrey
  • Alexandra Albin
  • Ben Heywood
  • Matt Cavallo
  • Marisa Zeppieri-Caruana
  • Jullia Hallisy
  • Dave deBronkart
  • Kerry Sparling
  • Tiffany M. Peterson

See them all here !

rob halkes's insight:

10 Lessons from empowered patients. Check them out!

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Medication management goes digital

Medication management goes digital | Patient Self Management |
Medication management for patients, as well as their physicians and pharmacists, is going digital.

Much of this is driven by the changing demographics of patients and today’s health care providers, says Nancy Green, managing principal, healthcare, of  Verizon Enterprise Solutions.

“Patients want technology that they are familiar with, and so does the younger generation of physicians,” Green says. “A CEO of a major health care organization recently went to his CIO and said, ‘Whatever IT the doctors or patients want, give it to them. Make it happen. I don’t care how.’”

Since doctors provide the billable services for hospitals, and patients (or their insurance companies) pay for them, this scenario is playing out all over the U.S. [...]

“Being able to present patient-centered information by way of a web-based graphic interface would likely provide the information and answers that many demand,” says Dr. Mark Leavey, an internist who sees patients at Lutherville Personal Physicians in Lutherville, Md., a satellite of Mercy Medical Center.

“Clearly, the paper printout supplied with medications by pharmacies may have all of the information, but it is presented in a form that is a challenge for any but the most well-versed to read.” 

Scanning a QR code directs users to information portals that display the prescription data in layers, with the most direct and basic facts first, followed by commonly asked questions and a video of proper ways to use the medication. [...]

“The system also includes an application that users can download on their phone or tablet for use in helping with chronic conditions by managing their taking of medications or monitoring other health-related tasks they must perform daily,” Hart said....

rob halkes's insight:

"They must perform daily .."  Sure! We need to focus at medication management, but: it will still be an issue as to what would be the best way to do it. We still don't know too much about how patients perceive and experience well intended interventions to their compliance. There's a thin line between facilitation and interference, yes, even the feeling of being meddled around with..
So, as we know: technology is just one, but making the right use of it for all parties concerned is definitely another matter.

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"Patient Engagement" in Health Care: Literature Review | Journal of Participatory Medicine

"Patient Engagement" in Health Care: Literature Review | Journal of Participatory Medicine | Patient Self Management |
The term "patient engagement" is at risk of becoming a vague buzzterm, as it lacks a shared definition. This paper aims to pinpoint the key conceptualizations of "patient engagement" from recent academic literature, in order to deepen understanding of the term.
rob halkes's insight:

Read it - and think about what you  "mean" when you talk about "patient angagement" - Informative!

Josefin Y-Dahlqvist's curator insight, September 2, 2014 4:08 PM

The Challenges of Conceptualizing Patient Engagement in Health Care

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" Flip the Clinic " | Maybe we all "flip" ..

" Flip the Clinic " | Maybe we all "flip" .. | Patient Self Management |

"How "Flipped" is your health practice?"

Flip the Clinic is a new Robert Wood Johnson Foundation project to re-imagine the medical encounter between patients and care providers.

What Exactly is Flip the Clinic?

Our goal is not only to create a specific set of practices that will improve the medical encounter, but also to inspire others to invent new ways to get more out of the clinic visit, too.

The first batch of resources for patients and providers launched in early 2014. But we’re not stopping there. The future of Flip the Clinic will be built from patient, care provider, and administrator input and ideas; it will be built from the advice of those willing to try something bold. We hope that will serve as a hub for innovative ideas already happening as well as a clearinghouse for what works and what doesn’t in the doctor-patient encounter. Flip the Clinic is an ongoing conversation, powered by your participation.

The traditional doctor’s visit is ripe for reinvention—both because it is such a valuable interaction, and because we know there are ways to make it better.

We believe that new tools, technologies, and strategies can empower people to be more informed and more engaged when they walk into the doctor’s office and better equipped to improve their health when they walk out the door. And we believe that doctors, nurses, and other care providers can improve the ways they communicate and engage with patients during visits. We believe they can take advantage of new tools for monitoring, supporting, and connecting with their patients outside of the office, too.

We think that by tapping into these strategies, we could to turn the provider-patient interaction on its head—and promote better, more meaningful relationships while doing so.

rob halkes's insight:

"Flip the Clinic" , or perhaps: Flip health care, seems to grow a new community/movement around better interaction between doctors and patients. A lot to be said of course, but I like the very attention to behaviour of the two parties here.

It will touch all issue of care, like interaction, communication, treatment, building and business. But one must go one stap at a time. I like it because it enters the controversial arena of medine and care interaction. The "flips" are very much to the point in my opinion, and they will draw attention to where it should be. It is just the other goal of disrupting care, not just the Health20 technology, but also engaging and participating care.

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Addressing health literacy through clear health communication: A training program for internal medicine residents

Addressing health literacy through clear health communication: A training program for internal medicine residents | Patient Self Management |
Patient Education and Counseling, Volume 95, Issue 1, Pages 76-82, April 2014, Authors:Jamie A. Green; Alda Maria Gonzaga; Elan D. Cohen; Carla L. Spagnoletti



To develop, pilot, and test the effectiveness of a clear health communication curriculum to improve resident knowledge, attitudes, and skills regarding health literacy.


Thirty-one internal medicine residents participated in a small group curriculum that included didactic teaching, practice with a standardized patient, and individualized feedback on videotaped encounters with real patients. Outcomes were assessed using a pre-post survey and a communication skills checklist.


Mean knowledge scores increased significantly from 60.3% to 77.6% (p<0.001). Residents also reported increased familiarity with the concept of health literacy (mean response 3.2 vs. 4.5 on a 5 point scale), importance placed on health literacy (4.2 vs. 4.9), frequency of considering health literacy in patient care (3.3 vs. 4.0), and confidence in communicating with low literacy patients (3.3 vs. 4.1) (all p<0.001). Use of plain language increased significantly from 33% to 86% (p=0.023). There were nonsignificant increases in the use of teach-back (0–36%, p=0.116) and encouraging questions (0–14%, p=0.502).


Training in clear health communication improves resident knowledge, attitudes, and skills regarding health literacy.

Practice implications

The increased use of clear health communication techniques can significantly improve the care and outcomes of vulnerable patients with limited health literacy.

rob halkes's insight:

Good to have prove that health literacy is crucial and practically teachable to medicine residents. One just has to to do it..;-)

Quote from the article: "A key strategy to reduce the impact of low health literacy is through improved provider-patient communication"

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Health researchers see unique opportunity in self-tracker data | mobihealthnews

Health researchers see unique opportunity in self-tracker data | mobihealthnews | Patient Self Management |

As the number of self-tracking health and fitness tools available to consumers continues to climb, a persistent question has been whether the data they collect might be useful to health researchers. Along with that: Are people who self-track comfortable sharing their data with researchers?

A new, must-read report from San Diego’s California Institute for Telecommunications and Information Technology (Calit2), funded by the Robert Wood Johnson Foundation, explores these and other questions.

Based on a survey with hundreds of self-trackers, a majority — 57 percent — said one critical assurance they would need before agreeing to make their self-tracked, personal health data available to researchers was that their privacy would be protected. More than 90 percent also said it was important that their data remained anonymous. Respondents said they’d be more comfortable sharing data if they knew it was only going to be used for “public good” research. ..

One open-ended survey that the report’s researchers posed to self-trackers found that 13 percent of respondents specifically mentioned an aversion to commercial or profit-making use of their data, according to the report. One respondent wrote: “It depends who gets it. Research using these data will be instrumental in the future of personal predictive services, but also for that reason are likely to be exploited by marketers and the politically short-sighted. Thus I would like transparency for who has access to my data.”

Among the almost 100 health researchers interviewed for the report, 46 percent said that they had already used self-tracking data in their research previously. Some 23 percent reported that they had already worked with digital health companies that offer apps or devices to consumers to track their health. Overall, the researchers interviewed for the report were “generally enthusiastic” about the prospect of using self-tracking data in the future — 89 percent agreed or strongly agreed that such data would prove useful to their research efforts. Almost all of those researchers surveyed said that kind of data could answer questions that other data could not. ..

rob halkes's insight:

The research results stresses two things:

- The serious issue of privacy and data safety: clients indeed bear great value to what their own opinion tells them to want regarding the (non)use of their data: every idea as in "Well they wouldn't bother because they would not know" is a highly misguided starting point (See how the purchase of whatsapp by Facebook initiated a change of messaging app by lots of whatsapp users);

- As health persons are already active so much with their own health then they will get more insights into their own body than physicians would have based upon their general knowledge of medicine. Imagine what that would imply for the physician - patient interaction. The trend to disrupting health care will be reinforced.

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Patient Engagement Approaches: Paternalist vs. Patient-Centered | HealthWorks Collective

Patient Engagement Approaches: Paternalist vs. Patient-Centered | HealthWorks Collective | Patient Self Management |
The evidence is clear that a patient-centered approach -- not a paternalistic, “we know best” approach -- is linked to increased patient engagement, better outcomes, more adherent patients, lower utilization and better patient experiences.


The setting was a presentation last week at HIMSS 2014. The presenter was Chanin Wendling, the Director of eHealth at Geisinger Health System. Channing was talking about Geisinger’s often cited HIT-driven patient engagement efforts which includes their patient portal, health apps and recent foray into “Open Notes.”

What struck me was Chanin’s description of philosophical approach and communication style employed by Geisinger in the course of developing the content for theses engagement tools...

Here’s what she said.

“We tend to think in a paternalistic way: this is what the patient needs, versus thinking ‘What will work best for the patient?’ and ‘How will the patient relate to whatever we’re prescribing?’ And that’s extremely important because at the end of the day, if you can’t get the patient to help, if they don’t take their meds, if they don’t lose the weight, if they don’t do their exercises, there’s nothing you as a clinician can do. You need the patient to help you.”

Here are two things that jumped out at me from Chanin’s comments;

1. Geinsinger’s patient communication style is paternalistic and physician-directed…meaning it is the direct opposite of a patient-centered philosophical approach and communication style.

A patient-centered style begins with an understanding of the very things Chanin says Geisinger ignores – what will work best for the patient and how patients will relate to a proposed intervention.

The evidence is clear that a patient-centered approach -- not a paternalistic, “we know best” approach -- is linked to increased patient engagement, better outcomes, more adherent patients, lower utilization and better patient experiences.

2. Geisinger’s attitude that patients are inherently unengaged, e.g., won’t help clinicians unless told by clinicians what they need to do, is why so many heath care providers are having difficulty engaging patients at all levels of the organization, including patient portals. Think about it: 82% of U.S. adults visit their doctor at least once a year because “they” think it’s the right thing to do…and Geisinger thinks they are “not willing to help”? Are you kidding me?

The problem today is not that patients are unengaged…but that many providers aren’t very engaging. Sure 50% of patient re non-adherent…but 20% of patient non-adherence has been attributed to poor communications on the physician’s part, e.g., paternalistic, physician-directed communications. Sure less than 10% of patients visit the average patient portal in a year…but when portal contents and functionality treat one like an uncooperative child why would one expect a higher level of adoption?

Via Chanfimao, Lionel Reichardt / le Pharmageek
rob halkes's insight:

Changing care for health isn't easy. Of course doctors will wrestle with on the one hand their "normative" medical evidence-based guidelines, and at the other a patient's understanding and need for guidance in their coping with both conditions and willingness to adhere to advice. A profession that knows how to bridge this dilemma is the teaching profession. Imagine.. Why not teach physicians as well.. ;-)

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FDA clears two wristworn fitness trackers for clinical trials | mobihealthnews

FDA clears two wristworn fitness trackers for clinical trials | mobihealthnews | Patient Self Management |

A British company, Camntech, has received FDA clearancefor a motion-tracking wristband and a wristworn electronic diary, likely for use in clinical trials.

The devices are called the MotionWatch 8 and PRO-Diary. According to the filing, the devices ”are intended for the acquisition and analysis of the physical activity of the body during daily living and sleep.” The devices upload data to a PC via a USB cord.

rob halkes's insight:

wearables, wearables... Indeed the future. But still, when it is not integrated with viewing, inspecting supporting information, will it be of practical, steady use.
There will be a phenomenon like half-time value to consumers' use. How to prolongue that needs to be a serious concern to the industry of wearables.

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Interaction between diabetes specialist nurses and patients during group sessions about self-management in type 2 diabetes

Interaction between diabetes specialist nurses and patients during group sessions about self-management in type 2 diabetes | Patient Self Management |
Patient Education and Counseling, Volume 94, Issue 2, Pages 187-192, February 2014, Authors:Eva Boström; Ulf Isaksson; Berit Lundman; Ulla H. Graneheim; Åsa Hörnsten

The aim of this study was to explore the interaction between diabetes specialist nurses (DSNs) and patients with type 2 diabetes (T2D) during group sessions about self-management.


Ten DSNs and 44 patients were observed during group sessions about self-management, and thereafter the observations were analyzed using qualitative content analysis.


The interaction was characterized by three themes: becoming empowered, approaching each other from different perspectives, and struggling for authority. The interaction was not a linear process, but rather a dynamic process with distinct episodes that characterized the content of the sessions.


It is important to achieve an interaction that is patient-centered, where the DSN is aware of each patient's individual needs and avoids responding to patients in a normative way. A satisfying interaction may strengthen patients’ self-management, and also may strengthen the DSNs in their professional performance.

Practice implications

Authority struggles between patients and DSNs could be a prerequisite for patients to become autonomous and decisive in self-management. DSNs might benefit from an increased awareness about this issue, because they can better support patients if they do not perceive authority struggles as threats to their professional role.

rob halkes's insight:

It's all in the conclusion, to quote: "t is important to achieve an interaction that is patient-centered, where the DSN is aware of each patient's individual needs and avoids responding to patients in a normative way. A satisfying interaction may strengthen patients’ self-management, and also may strengthen the DSNs in their professional performance."

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