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Steve Freed: This is Steve Freed with Diabetes in Control, and we are here in San Diego for the American Diabetes Association 77th Scientific Sessions, and we have some really great interviews with some of the top endocrinologists from all across the globe. We have a special guest with us today, Emily Seto, PhD, PEM. Can you start off by telling us a little bit about yourself?
Emily Seto: Sure. I am an engineer by background, actually and right now I work at the University of Toronto and I am the lead for the health informatics programs there. I’ve also been doing research in the field of mobile health for the past 14 years or so and looking at how do we improve chronic disease management through use of these types of technologies.
Steve Freed: I know you’re presenting here. What is the title of your presentation?
Emily Seto: So, I was looking at the successes and failures of mHealth in chronic disease management.
Steve Freed: Can you explain to us what mHealth is?
Emily Seto: So mHealth is mobile health. It is an emerging field — kind of a subset of eHealth, so basically looking at how mobile technologies can be used in healthcare. So, you’re talking about health apps such as those wearables like Fitbit and things like that.
Steve Freed: So there are a lot of diabetes apps out there. We try to keep a list and it changes on a daily basis. Most people put together apps that have no history behind them. So, what makes the mHealth app different?
Emily Seto: So mHealth is the category of health apps, so in terms of what we kind of do in our lab is that we’ve created a number of different types of health apps that are geared towards chronic disease management. We do it in collaboration with patients and a lot of clinicians and we get the feedback through iterative usability design and really understanding the needs of the patients. We also provide evidence; we do trials to try to figure out whether or not it’s actually helping patients and also the providers, and if it’s actually saving the healthcare system any money.
Steve Freed: How long have you been doing this?
Emily Seto: Looking at mHealth, about 10 years now we’ve been doing this.
Steve Freed: Ok so in those 10 years, what have you developed as far as apps go?
Emily Seto: We have a number of apps, I’ll just maybe mention one or two. The first is a platform for chronic disease management that we called, Medly. The idea here is that it can be used for single chronic conditions or for people with multiple chronic conditions as well. It’s a telemonitoring system so patients at home take the required measurements that they normally would do. So maybe blood sugars for diabetes, or if you have heart failure, weight and blood pressure. Then also, any symptoms you may have. So this is all automated through Bluetooth enabled devices and it automatically transfers to the cell phone, which acts as “the hub,” and then from there, it gets sent to data servers where we have algorithms that we spent a lot of time working on with clinicians to create an algorithm so that, in real time, the patients get self-care messages back through the app. Then the care providers can get alerted at the earliest signs that the patient is getting worse and then they could intervene and close that loop and provide, for example, education over the phone or even changing medication. Really, the idea is to keep patients from going into hospitals over and over again.
Steve Freed: So what you do, it’s not just about diabetes?
Emily Seto: Oh no, [although] we also have apps for diabetes as well. One is called Bant. It is a free app that’s available on the iTunes store right now. We’ve created a number of different apps, some for diabetes and some for other chronic diseases as well.
Steve Freed: And do you do studies with these apps to see if they actually improve?
Emily Seto: Yes, absolutely. So after we have created them, we always start out with some pilot trials to see how it kind of fits into the healthcare system. We iron it out to make sure that everything is in place before we do larger trials such as randomized control trials, and then we make sure that it’s ready for deployment. Of course our end goal is to deploy it out for real-use by patients and clinicians.
Steve Freed: So because A1C is the gold standard, have you done studies to see if it lowers A1C? If it does lower A1C, it is a good program. If it doesn’t change, you throw it away, and start all over again.
Emily Seto: Well, I hope that is not the case! (Laughs) Actually showing A1C change can be quite difficult and you need a lot of patients to do that. We have been doing studies, for sure, looking at A1Cs. We have also been looking to see if your blood sugar readings are in range and also how many times, for example, do you take your blood sugar readings if you are a type 1 diabetic. Also looking at, for type 2 diabetes, whether or not you are following good lifestyle changes, right? So, are you eating properly, are you exercising properly, and then kind of correlating all of that information so the patient can actually have control over what they’re doing and understand how it relates to the diabetes. So I think there’s a lot more to it than just hemoglobin A1C values, but certainly, we have done studies looking at that as well.
Steve Freed: So for mHealth, do you try to work with apps for medical professionals or patients, or both?
Emily Seto: Both. So it depends on the type of app. Sometimes if you’re looking at the diabetes app, maybe it is purely for self-care and then the patients is using it. We also have apps for diabetes that connect patients to their clinicians and again, we try not to give the clinician reams of data to look at because they are extremely busy. So we definitely want to make sure their time is utilized properly. Through smart algorithms, we can alert them when they actually need to be intervening to help their patients. So if patients’ blood sugars are completely out-of-whack for a trending, for example, or hypoglycemic, then we could alert the appropriate care providers to intervene at that time.
Steve Freed: What is the biggest challenge to mHealth realizing its potential in helping with diabetes management?
Emily Seto: I think part of the challenge is getting patients to use it for long-term. So a lot of people who download apps or use wearables, for example, they have this honeymoon phase where it’s kind of cool to use for a little while, and then they stop using it. So how do you make these types of technologies sticky so that they are used long-term? I think there are a lot of opportunities around, first of all, making it so valuable that people want to keep using it. And then also, making it super easy to use so that it gets within the routine. We want it to become like brushing your teeth. So checking blood sugars through these apps is just something that you do every day. There are also opportunities around doing more novel things like adding gamification into things or a social networking which seems to work very well with adolescents, for example, with type 1 diabetes. And then there are also ideas around using reward systems. For example, the Care Reward app is really well-known and it has some really good benefits of doing that and so we’ve also looked at giving air miles, for example, to incentivize people to start using and to keep using apps.
Steve Freed: How long ago did you start doing this?
Emily Seto: It’s about 10 years now.
Steve Freed: I would think that it would be less than that, when it comes to apps and the popularity and what we’re doing with them because, if you think about it, you wouldn’t have a job in this industry 12 years ago and because of that, it is done for new jobs, because of demand for people. What kind of people are you looking for when it comes to hiring people to do this?
Emily Seto: If I could just comment, first of all, the first part of your statement, I think, is absolutely true. I mean 10 years ago, we’re looking at very different types of technologies. You were looking at a lot of tech space and typing it into very old types of cell phones. So we started early and the types of technologies we were using before were completely different than now. In terms of the people who are working in this space now, it is complete interdisciplinary. So we have people who are creating the apps, obviously, we have the developers, graphic designers, but we also have people who understand behavior, especially behavior of patients and what it is that we can try to do to motivate them to tweak their behavior for the positive. We also have a lot of researchers on the end and then we work really closely with patients, as I mentioned, and clinicians for developing these. So we never start out developing anything without a clinical champion who really understands the problems that we’re trying to solve because we don’t want to ploy technology just for technology’s sake. We want to make sure that it is solving a real need.
Steve Freed: And how do deal with using mHealth with people who do not have smartphone technology or do not have the means to pay for mobile technology?
Emily Seto: Right. So I think it is interesting because now the majority of people actually do have smartphones and the trend is going that more people have cell phones than they have toothbrushes, for example. And so I don’t think it is something that we need to worry about so much in the future and honestly, these type of mobile technologies can actually be looking at sort of leveling the playing field. So people who don’t have access probably to computers can have access to cell phones and there’s very interesting studies [that] are going on right now giving cell phones to people who are vulnerable, such as the homeless, and you get connected through Wi-Fi, for example. So I think that we have to look at this as an opportunity to kind of reach people and connect people to healthcare services and providers that normally don’t have it. I guess the other comment is for those people who don’t have it, none of this technology is for everybody. We are trying to hit a population that we can help, and again, I think that in the future, this probably won’t even be a problem in a few years.
Steve Freed: How do you find this technology is changing into the future? I mean next year when you come here, and you call a cab, it’ll pull up and there won’t be a driver in it, but there will be an announcement, “Hello,” and they will announce your name, and say, “Thank you, you look great today, where would you like to go?” If that was to happen today would you get in that car?
Emily Seto: (Laughs) Would I get in that car? Probably not today because I do not think it is ready yet and I think that’s the case with some of our mHealth technologies. Not everything is created equally and there are a lot of technologies that are just not ready for primetime yet. So there are lots of talks about contact lenses that will get your blood sugars or watches that will accurately get your blood sugars. They’re not quite ready for primetime but I think that, certainly, the research is kind of advancing that area. You are going to see a lot more wearable technology and even implanted technologies, like for example, the artificial pancreas; it’s coming. So it’s not that far that we’re going to have implanted technologies and also, potentially looking at continuous glucose monitoring and using a cell phone as the brains to control the dose of insulin you’re going to get, those kind of closed loop systems I think are coming in the future and we’re going to see a lot more of that. We’re also going to see smart technology in homes. So things that you won’t even notice, like stepping into your washroom and you’ll be taking your weight, so that sort of thing. There is a lot of embedded technologies into homes that I think will be coming up in the future.
Steve Freed: So how do you determine what’s next? So you sit around a table and you discuss, “What are we going to do next? What is our next project?” You probably have a list of 10 or 20 things that you want to accomplish. What are some of those things that you are looking at into the future?
Emily Seto: So I think right now, obviously, we want to do something that is impactful and I think, at least in my area, what I’m interested right now in doing is targeting patients who have those multiple chronic conditions. I think those are the people, for sure, actually, who are taxing the healthcare system; they are the ones who are getting re-hospitalized over and over again – several times a month potentially, and so, I’m interested in helping that population, because again, I think they’re in the great need. So we have a great project that’s coming out that I’m very excited about looking at how we can get our platform to be truly useful in terms of people with multiple conditions, including mental health issues. So if they have depression or anxiety, which is often the case when you are very sick, how do we support them in a holistic-type-of-way on one platform, and looking at how we integrate that into our healthcare system because that’s the trick – it’s really hard to get our technology in place so that it is meaningfully used by the patients but also with the clinicians. It has to work within their workflow and it also has to not take too much of their time – there has to be a benefit to the providers or else they’re just not going to adopt technology as well.
Steve Freed: Well there is a lot of competition out there when it comes to apps. If you do a search on the Internet there’s people that work out of their homes, there’s a lot of universities – what makes mHealth different?
Emily Seto: In terms of that we do as a group?
Steve Freed: (Nods yes.)
Emily Seto: Just to take to the table again, the way that we do our development is that we do not start without a need. If it exists and it works, well then we probably won’t touch it. So we make sure there is a need, we make sure that we have the right clinicians that are involved, and this is usually a team of people, not just physicians, but nurse practitioners, nurses, diabetes educators, etc., who are around to help with the development. We also are tapped into the patients. So I’m from the University Health Network and I do some research there and so our research group is actually based in the hospital. We have access to patients and providers who come over and over again to test our equipment. We give them a version, it can be on paper, and they tell us what works and what doesn’t and then we iterate on that. So, by the end, we’re pretty confident that we have a pretty good piece of technology. I think the other piece again, is that we do the evaluation – we’re very strong in doing pilot trials all the way to very more sophisticated randomized control trials to provide evidence that our apps actually work. We also spend a ton of time looking at how to implement things into the healthcare system – we do workflow analyses and talk to the patients and the providers to see how it can fit into their lives. We spend a ton of time doing that because that will make or break a deployment. So we spend a lot of time trying to make sure that it will work within that healthcare system.
Steve Freed: So everything is 100% dealing with healthcare?
Emily Seto: Yes. We specialize in healthcare only. We don’t do apps for gaming purposes.
Steve Freed: Well there are gaming apps for health.
Emily Seto: Oh yes, there are. As I have said before, we’re putting in some gaming features into some of our apps, but our strength is understanding healthcare, so we stay with that.
Steve Freed: So if someone wanted to find out more about what kind of apps that are available for a medical professional, are there any apps for patients? Where could they go to get that information?
Emily Seto: Yes, that is a really good question. I mean I think that’s one of the things that is an obstacle right now, in our field, is that there are so many apps out there. Last count, there were over 165,000 health apps, so how do you know which is good and what is going to help you? I don’t think patients actually do know and that’s why very few of those 165,000 apps are actually used very much. Some of them are not designed very well and may not be useful, so we need to support patients in figuring out which ones are good. There is a concept out now for prescribing apps. We partner with clinicians and when a clinician says to a patient, “I think this app is going to help you,” and then when it’s embedded in our clinics, I think there is a better chance that patients are going to use it. Also if the app is by an organization that is well-known, such as the Heart and Stroke Foundation, for example, then I think it is more likely that patients will use that as well. There’s been work that governments, for example, are trying to find a way to vet apps to see which ones are good and which ones are bad, but it is very tricky because different apps have different definitions of what good is and what’s the benefit. So that is a continuous thing that we are trying to figure out.
Steve Freed: So if I had an idea for an app, could I come to you and see if you would be open to helping to develop it?
Emily Seto: Sure. (Laughs) Always open to new ideas. Again, we start out by need, so if there is a need and it is possible to do it, then we always partner with patients and providers to do it and we always make sure we have providers that think it is a good idea to carry out an app. It’s hard to even predict what we will be doing in the next few years. We do have some plans that are kind of short-term, but there are all kinds of new opportunities and new technologies that are coming out that we are embedding into our systems and we’re always keeping an eye out for that sort of thing.
Steve Freed: Do you have a website?
Emily Seto: We do. So the research is done through the Center for Global eHealth Innovation. If you google that, you will find our eHealth website, ehealthinnovation.org, and you will find more information about what we do.
Steve Freed: Well I want to thank you for your time. Certainly enjoy the rest of your time here and thank you for stopping by.
Emily Seto: Great, thank you very much, it was a pleasure.